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n\ 


JDISEASES 


OF 


THE  INTESTINES  7 


A  TEXT-BOOK  FOR  PEACTITIONERS  AND 
STUDENTS  OF  MEDICINE 


MAX   EINHORN,  M.D. 

PROFESSOR   OF   MEDICINE   AT  THE   NEW    YORK    POST-GRADUATE   MEDICAL 
SCHOOL   AND   HOSPITAL,    AND   VISITING    PHYSICIAN    AT 
■     THE  GERMAN    DISPENSARY,    NEW    YORK 


NEW  YORK 
WILLIAM   WOOD   AND   COMPANY 

MDCCCC 


Wo 


CopraiOBT,  1900 
By  WILLIAM  WOOD  AND  COMPANY 


TO 
MY   ESTEE^IED  FRIEND  AND  TEACHER 

ERXST  VON  LEYDEN,  M.D. 

PROPKSSOR  OF  MEDICINE   IN"  THE   I'MVERSITY  OF   BERLIN 
THIS    BOOK 

IS  RESPECTFULLY  DEDICATED 


PREFACE. 


This  treatise  is  a  continuation  of  mj*  work  on  "  Diseases 
of  the  Stomach,"  the  two  together  comprising  the  princi- 
pal disorders  of  the  digestive  tract.  In  discussing  the 
subject  of  the  intestinal  affections  an  effort  has  been  made 
to  follow  the  same  lines  laid  down  in  my  book  on  the 
stomach.  The  practical  points  regarding  diagnosis  and 
treatment  are  always  placed  in  the  foreground. 

Although  our  knowledge  of  diseases  of  the  intestines  has 
not  made  such  rapid  progress  as  that  of  morbid  conditions 
of  the  stomach,  much  has  likewise  been  achieved  in  this 
field.  Surgery  has  made  many  successful  advances.  The 
elucidation  of  the  intimate  relation  existing  between  func- 
tional disturbances  of  the  stomach  and  of  the  intestines 
also  marks  an  important  stej)  forward,  especially  as  to 
therapy. 

While  there  are  many  excellent  works  on  intestinal  dis- 
eases by  German  authors,  the  more  recent  English  litera- 
ture contains  no  monographs  on  this  important  subject. 
The  medical  encyclopedias,  it  is  true,  contain  very  instruc- 
tive contributions  on  this  topic,  and  among  these  Ewald's 


Vi  PREFACE. 

treatise  on  diseases  of  the  intestines  in  the  "  Twentieth  Cen- 
tury Practice  of  Medicine  "  is  a  most  valuable  acquisition. 
The  present  volume,  it  is  hoped,  will  to  a  certain  extent 
fill  the  void  in  Aiperican  literature  of  a  monograph  on  the 
affections  of  this  portion  of  the  digestive  tract.  The  writer 
desires  to  express  his  indebtedness  to  Nothnagel,  Kosen- 
heim,  Boas,  Fleischer,  Ewald,  Pick,  Fowler,  Treves,  and 
Allingham,  whose  works  have  been  frequently  consulted. 
He  trusts  that  this  book  will  prove  of  practical  utility  to 
the  practitioner,  and  if  it  will  aid  him  in  more  successfully 
treating  this  class  of  cases,  the  author's  effort  will  be  more 
than  recompensed.  Max  Einhorn. 

New  York,  April,  1900. 


CONTENTS. 


CHAPTER  I. 
Anatomy  and  Physiology. 

PAOK 

Anatomy, 1 

The  Intestinal  Canal  (Intestinum) 1 

The  Duodenum. 1 

The  Small  Intestine, .4 

Structure  of  the  Small  Intestine,        ....  6 

The  Large  Intestine  or  Large  Bowel  (Intestinum  Crassum),     .  11 

Histology  of  the  Large  Bowel,    .        .  .17 

Physiology, 18 

1.  The  Secretory  Function  or  the  Chemical  Processes  in  the 

Intestines 18 

2.  Absorption .         .  24 

3.  Motion 38 

CHAPTER  II. 
Methods  of  Examination  and  Treatment. 

Examination 32 

Interrogation 32 

Inspection, 34 

Proctoscopy, 37 

Palpation,           ...                 40 

Percussion,         .        .                 ......  44 

Auscultation,      .        .                                         ....  45 

Inflation  of  the  Intestine  with  Carbonic  Acid  Gas  or  Air,  45 

Injection  of  Water  per  Anum, 48 

Ijavagc  of  the  Bowel. 48 

Examination  of  the  Faeces 49 

Treatment 74 

Diet, 74 

Mechanical  Procedures,      .        .                         ....  78 

Injections, 78 

Massage  and  Gymnastic  E.xercises 80 


Vlll 


CONTENTS. 


Mechanical  Procedures: 
Hydrotherapy,     . 
Electricity, 


•80 
81 


CHAPTER  III. 
Acute  and  Chronic  Intestinal  Catarrh. 

Acute  Intestinal  Catarrh, 
Synonyms, 
Definition, 
Etiology,    . 
Morbid  ^Vjiatomy, 
Symptomatology, 

General  Subjective  Symptoms, 

Objective  Symptoms, 

Fever, 
Localization  of  the  Catarrhal  Process, 
Duration,    . 
Diagnosis, 
Prognosis, 
Treatment, 
Chronic  Intestinal  Catarrh, 
Synonyms, 
Definition, 
Etiology,    . 
Morbid  Anatomy, 
Symptomatology, 

Objective  Symptoms^ 
Course, 
Diagnosis, 
Prognosis, 
Treatment, 

Hydrotherapeutic  Measures, 

Mineral  Waters, 

Medicaments, 


83 

83 

83 

83 

85 

86 

87 

88 

89 

89 

90 

91 

91 

91 

94 

94 

94 

94 

95 

98 

99 

103 

103 

104 

105 

106 

107 

107 


CHAPTER  IV. 

Dysentery. 

Dysentery, 110 

Synonyms, .  110 

Definition, 110 

Etiology, 110 

Morbid  Aiiatomy, 115 


CONTENTS. 


IX 


Dysentery : 

Symptomatology  of  Acute  Dysentery, 
Symptomatology  of  Chronic  Dysentery, 
Course,       ... 

Complications, 

Diagnosis, 

Prognosis,  .      '  . 

Treatment  of  Acute  Dysentery, 
Treatment  of  Chronic  Dysentery, 


PACK 

.  119 
122 
.  123 
.  123 
.  125 
.  125 
,  125 
126 


CHAPTER  V. 
Ulcers  of  the  Intestines. 


Duodenal  Ulcer,   . 

Synonyms, 

Definition, 

Etiology.    . 

Morbid  Anatomy, 

Situation  of  the  Ulcer, 

Symptomatology, 

Course, 

Diagnosis, 

Prognosis,  . 

Treatment, 
Embolic  and  Thrombotic  Ulcers, 

Pathological  Changes, 

Symptoms, 

Diagnosis, 

Prognosis, 

Treatment, 
Amyloid  Ulcers, 

Diagnosis, 
Tuberculous  Ulcers, 
Syphilitic  Ulcers, 
Toxic  Ulcers, 

Symptomatology, 

Diagnosis, 

Prognosis, 

Treatment, 


CHAPTER  VI. 
Neoplasms  of  the  Intestine. 


Malignant  Growths, 
Cancer, 


128 
128 
128 
128 
129 
130 
131 
133 
133 
134 
134 
135 
135 
136 
138 
13^ 
139 
140 
141 
141 
144 
145 
145 
147 
148 
148 


150 
150 


X  CONTENTS. 

PAQK 

Cancer : 

Defiuition 150 

Etiology 150 

Location, .  151 

Morbid  Anatomy, 152 

Symptomatology, 154 

Course, *       .        .        .        .  163 

Diagnosis 163 

Prognosis 164 

Treatment, 164 

Sarcoma  and  Lympho-Sarcoma, 166 

Benign  Tumors  of  the  Intestine, 167 


CHAPTER  VII. 
Hemokrhoids. 


Hemorrhoids,    . 
Synonyms, 
Definition. 
Etiology,    . 
Morbid  Anatomy, 
Symptomatology, 
Diagnosis. 
Prognosis. 
Treatment, 

Radical, 
Complications, 

Prolapse  of  the  Rectum. 

Fissure  of  the  Anus,    . 


169 
169 
169 
169 
171 
174 
179 
180 
180 
185 
189 
189 
193 


CHAPTER  Vni. 


APPENDICms. 


Appendicitis,     . 
Synonyms, 
Definition, 
General  Remarks, 
Etiology.    . 
Morbid  Anatomy, 
Symptomatology, 
Course, 
Diagnosis, 
Differential  Diagnosis, 
Prognosis, 


196 
196 
196 
196 
197 
202 
206 
208 
214 
215 
216 


CONTENTS.  Xi 

PAGK 

Appendicitis: 

Treatment,  218 

Medical 218 

Surgical, 221 

CHAPTER  IX. 

Intestinal  Obstruction. 

Introductory  Remarks, 226 

Acute  Intestinal  Obstruction, .        .  227 

Synonyms, 227 

Definition, 227 

Etiology .        .        .227 

Compression  of  the  Intestine 227 

Strangulation  by  Adhesions, 228 

Strangulation  by  Meckel's  Diverticulum,  ,        .        .  230 

Volvulus, 232 

Obturations 233 

Intussusception, 234 

Pathological  Changes 236 

Symptomatology 238 

Objective  Signs, 245 

Course 247 

Diagnosis,     • 249 

Prognosis, 258 

Treatment 258 

Medical, 258 

Surgical 266 

Chronic  Intestinal  Obstruction, 268 

Etiology, 268 

Symptomatology, 269 

Complications 276 

Course  and  Prognosis, 277 

Diagnosis,  .         .  277 

Treatment, 278 

Operative  Intervention, 280 

CHAPTER  X. 

Nervous  Affections  op  the  Intestines. 

General  Remarks, 282 

Motor  Neuroses  of  the  Intestines, 284 

Diarrhoea, 284 

Etiology  and  Symptomatology, 284 

Diagnosis, 289 


xu  CONTENTS. 

PAGX 

Diarrhoea : 

Prognosis,    .  889 

Treatment 289 

Constipation, 291 

Synonyms, 291 

Definition, 291 

Greneral  Remarks 291 

Etiology, 292 

Symptomatology 297 

Diagnosis 302 

Prognosis, 304 

Treatment, 304 

Moral 305 

Dietetic 305 

Mechanical, 306 

CHAPTER  XI. 
Nervous  Affections  of  the  Intestines. 

Motor  Neuroses  (Continued), 314 

Paralysis  of  the  Intestines, 314 

Diagnosis 315 

Treatment, 315 

Proctospasmus,  or  Spasm  of  the  Rectum, 316 

Diagnosis.    .        .        .       ' 317 

Treatment 317 

Paresis  and  Paralysis  of  the  Sphincters  of  the  Anus,         .        .  317 

Diagnosis 318 

Prognosis 318 

Treatment, 318 

Peristaltic  Restlessness  of  the  Intestines, 319 

Definition, 319 

Etiology  and  Symptomatology, 319 

Diagnosis 320 

Prognosis, 320 

Treatment, 320 

Meteorism, 321 

Etiology 321 

SjTnptomatology 322 

Diagnosis, 323 

Prognosis, 323 

Treatment 323 

Sens<iiy  Neuroses  of  the  Intestines, 325 

Enteralgia 326 


CONTENTS.  xiii 

PAGK 

Enteralgia : 

Synonyms,           .         .        . 326 

Definition 326 

Etiology 326 

Symptomatology, 327 

Diagnosis .  329 

Prognosis, 330 

Treatment, 330 

Hypogastric  Neuralgia 332 

Treatment 333 

Hypersesthesia,  Parsesthesia,  and  Anaesthesia  of  the  Intestine,  333 

Treatment. 334 

Secretory  Neuroses  of  the  Intestines 335 

Membranous  Enteritis, 335 

Synonyms, 335 

Definition 335 

History, 335 

Etiology .         .         .339 

Symptomatology, 341 

Diagnosis, 343 

Treatment, .        .344 

Intestinal  Neurasthenia 347 

Diagnosis 348 

Treatment 348 

CHAPTER  XII. 

Intestinal  Parasites. 

General  Remarks 349 

Protozoa, 349 

AmcBba? 349 

Sporozoa 350 

Infusoria 350 

Vermes 351 

Cestodes  (Tape  Wonns) 351 

General  Remarks 351 

Taenia  Solium .  354 

Taenia  Saginata  or  Mediocanelluta 355 

Bothrioceplmlus  Liitus,  Taenia  Lata,  or  Pig  Head.  .  357 

T«nia  Nana 358 

Taenia  Cucumcriua 358 

Taenia  Flavopunctata  or  Taenia  Diminuta,  .  359 

Treatment 359 

Trematodes  (Fluke  Worms) 862 


XIV  CONTENTS. 

PAGE 

Trematodes  (Fluke  Worms) : 

Distoma  Hepaticum  or  Liver  Fluke,  ....  362 

Distoma  Lanceolatum, 363 

Distoma  Haematobium  or  Bilharzia  Hsematobia,  .  364 

Nematodes  (Round  Worms) 365 

Ascaris  Lumbricoides  (Common  Spool  or  Hound  Worm),     .  365 

Diagnosis 367 

Symptoms .  367 

Prophylaxis 368 

Treatment, .368 

Ascaris  Mystax, 369 

Oxj'uris  Vei-micularis,  Awltail,  Seat  or  Pin  Worm,  Maggot 

or  Thread  Worm, .369 

Symptoms 370 

Diagnosis 371 

Prophylaxis, 371 

Treatment, 371 

Anchylostoma  Duodenale,  Dochmius  Duodenalis,  or  Stron- 

gylus  Duodenalis, 372 

Symptoms, 374 

Course, .375 

Diagnosis, 375 

Treatment, 376 

Anguillula  Stercoralis, 376 

Anguillula  IntestinaliS, 376 

Trichocephalus  Dispar,  Whip  Worm,         ....  377 

Symptoms, 377 

Diagnosis, 377 

Trichina  Spiralis, 379 

Prophylaxis, 380 

Treatment 380 


DISEASES  OF  THE  INTESTINES. 


CHAPTER  I. 

ANATOMY  AND  PHYSIOLOGY. 

ANATOMY. 
The  Intestinal'  Canal  (Intestinum). 
The  intestinal  canal  may  be  divided  into  two  parts,  the 
small  intestine  and  the  large  intestine  (Fig.  1).  The  small 
intestine  (intestinum  tenue)  is  about  seven  to  eight  metres 
long,  the  first  portion  being  called  the  duodenum,  the  sec- 
ond the  jejunum,  and  the  third  the  ileum.  With  the  ex- 
ception of  the  duodenum  the  small  intestine  lies  for  the 
most  part  inside  the  more  fixed  portion  of  the  large  intes- 
tine and  is  connected  to  the  posterior  abdominal  wall  by 
the  mesentery.  This  broad  membrane  extends  from  above 
downward  and  from  left  to  right,  from  the  end  of  the  duo- 
denum above  to  the  ileocaecal  valve  below,  enclosing  the 
jejunum  and  ileum  along  the  whole  of  their  extent. 

TJie  Duodenum. 

The  duodenum,  so  called  on  account  of  its  length  (being 

about  twelve  inches  long),  is,  unlike  the  other  parts  of  the 

small  intestine,  very  definite  in  position  and  extent.     It  is 

that  part  which  is  not  suspended  by  the  mesentery.     It  is, 

further,  the  most  fixed  as  well  as  the  widest  part  of  the 

small  intestine,  measuring  one  and  one-half  to  two  inches 
1 


2  DISEASES  OF  THE  INTESTINES. 

in  diameter.  It  has  a  curved  shape,  somewhat  resembling 
that  of  a  horseshoe.  It  surrounds  the  pancreas  and  is 
divided  into  four  parts : 

1.  The  superior  horizontal  portion  (pars  horizoutalis 
superior)  begins  at  the  pylorus,  lying  at  the  level  of  the 
first  lumbar  vertebra,  and  runs  slightly  upward  and  back- 
ward toward  the  right  until  it  reaches  the  right  side  of  the 
vertebral  column.  It  ends  at  the  neck  of  the  gall  bladder, 
and  is  the  most  movable  of  the  four  portions.  It  is  cov- 
ered by  the  two  layers  of  the  peritoneum  which  are  contin- 
ued from  the  stomach,  and  by  these  it  is  completely  sur- 
rounded. Above  it  lie  the  liver  (quadrate  lobe)  and  the 
gall  bladder,  below  it  is  the  pancreas,  and  behind  it  are  the 
common  bile  duct  and  hepatic  vessels. 

2.  The  descending  i:>ortion  of  the  duodenum,  beginning  at 
the  neck  of  the  gall  bladder,  is  about  twice  as  long  as  the 
first  portion,  and  runs  almost  vertically  to  the  second  or 
third  lumbar  vertebra.  It  lies  to  the  right  of  the  lumbar 
vertebra?,  and  touches  the  right  kidney.  In  front  of  it  and 
crossing  it  almost  at  a  right  angle,  runs  the  transverse 
colon.  It  is  more  fixed  than  the  first  portion.  On  its  left 
side  is  the  pancreas,  and  the  common  bile  duct  a  little 
more  posteriorly.  Into  this  part  of  the  bowel,  and  at  its 
inner  and  back  part,  but  four  inches  from  the  pylorus,  the 
common  bile  duct  and  i>ancreatic  duct  enter.  The  portion 
at  which  these  ducts  enter,  occasionally  forms  a  small  sinus 
(diverticulum  or  ampulla  Vateri). 

3.  The  third  part  or  the  transverse  portion  is  the  longest, 
measuring  about  five  inches.  It  extends  from  the  base  of 
the  second  or  third  lumbar  vertebra  on  the  right  side 
obliquely  across  the  spine  to  the  upper  part  of  the  left  side, 
ascending  a  little  on  its  way.  In  front  of  it  is  found  the 
lower  layer  of  the  transverse  mesocolon.     The  superior 


ANATOMY. 


mesenteric  vessels  cross  this  part  of  the  duodenum,  running 
between  it  and  the  pancreas  in  order  to  reach  the  mesentery. 
This  portion  is  in  relation  with  the  pancreas  and  superior 


Fig.  1.— The  Intestine,  as  Seen  from  the  Front,  after  Removing  the  Omentmn  (Testut). 
1.  Abdominal  wall ;  3,  wall  of  the  thorax  ;  3.  a?sophagiis ;  3',  cardia ;  4,  stomach  ;  4', 
pylorus;  5,  duodenum;  6,  pancreas;  7,  liver;  8.  gall  bladder;  9,  gastrohepatlc  liga- 
ment ;  10,  right  kidney  and  its  suprarenal  capsule ;  11,  small  intestine ;  12,  terminal 
portion  of  the  Ileum ;  13,  cieeum  :  13',  its  appendix  ;  14,  ascending  colon ;  15,  transverse 
colon ;  16,  descending  colon ;  17,  ileopelvic  colon ;  18,  bladder ;  19,  parietal  peritoneum ; 
30,  spleen ;  31,  diaphragm ;  22,  thoracic  aorta. 

mesenteric  artery  above,  with  the  vena  cava,  aorta,  and 
crura  of  the  diaphragm  behind.  It  is  the  most  fixed  por- 
tion of  the  duodenum. 


4  DISEASES  OF  THE  INTESTINES. 

4.  The  fourth  part  of  the  duodenum  or  second  ascending 
portion  ascends  vertical!}'  at  the  left  side  of  the  spine.  It 
is  aboat  one  inch  long  and  forms  the  end  of  the  duodenum. 
It  is  firmly  fixed  in  its  place  by  the  musculus  suspensorius 
duodeni,  the  latter  being  the  name  of  the  fibrous  band, 
containing  some  plain  muscular  fibres  which  descend  to  the 
vertical  part  of  the  duodenum  from  the  left  crus  of  the 
diaphragm  and  the  tissues  about  the  cosliac  axis.  It  ter- 
minates at  this  point  in  the  jejunum,  forming  theflexura 
duodenojejunalis  at  a  place  situated  to  the  left  of  the  sec- 
ond lumbar  vertebra. 

The  Small  Intestine. 

The  small  intestine  which  forms  the  continuation  of  the 
duodenum  is  composed  of  the  jejunum  and  ileum.  There 
is  really  no  marked  structural  difference  between  the  two, 
and  it  is  therefore  hardly  possible  to  determine  where  one 
ends  and  the  other  begins.  As  a  rule,  the  upper  two-fifths 
are  designated  as  the  jejunum  and  the  lower  three-fifths  as 
the  ileum.  The  jejuno-ileum  fills  the  greater  part  of  the 
abdomen.  It  occupies  the  umbilical,  hypogastric,  iliac, 
and  lumbar  regions,  and  is  more  or  less  encircled  by  the 
large  intestine.  The  coils  formed  by  the  jejunum  and 
ileum  are  very  movable  and  completely  invested  by  the 
peritoneum.  They  are  supported  and  attached  to  the  pos- 
terior parietes  by  the  mesentery.  The  latter  extends  from 
the  end  of  the  duodenum  to  the  ileocecal  junction.  The 
point  at  which  the  mesentery  is  attached  above  is  on  a  level 
with  the  lower  border  of  the  pancreas  and  just  to  the  left 
of  the  vertebral  bodies.  From  this  point  of  insertion  the 
mesentery  follows  an  oblique  line  running  downward  and 
to  the  right,  crossing  the  great  vessels  and  ending  in  the 
iliac  fossa.     The  length  of  the  mesentery  from  the  spine 


ANATOMY.  5 

to  the  intestines  varies  in  different  parts  of  the  canal,  its 
average  being  eight  to  nine  inches.  It  soon  attains  its  full 
length,  and  within  one  inch  of  the  end  of  the  duodenum  is 
already  six  inches  long.  The  small  intestine  hangs  on 
the  mesentery  in  the  form  of  coils,  and  the  folds  which  the 
mesentery  forms  may  be  compared  to  those  of  a  fan. 

The  small  intestine  including  the  duodenum  has  an  aver- 
age length  of  about  twenty  feet.  The  calibre  of  the  small 
intestine  is  larger  at  its  upper  end  and  gradually  dimin- 
ishes in  size  until  its  entrance  into  the  large  bowel.  Thus 
at  the  beginning  the  jejunum  has  a  calibre  of  17.5  cm., 
the  ileum  at  its  beginning  of  11.5  cm.,  and  at  its  end  9.5 
cm.  The  ileum  passes  perpendicularly  into  the  ascending 
part  of  the  larger  bowel  just  above  the  caecum,  its  mucosa 
forming  a  double  valve,  called  valvula  Bauhini.  The  jejuno- 
ileum  is  the  most  movable  part  of  the  intestinal  tract. 
Wherever  a  free  space  is  left  it  occupies  it.  It  is  therefore 
most  often  m6t  with  in  hernias.  During  gravidity  or  when 
a  tumor  or  ascites  exists  in  the  abdomen  the  small  intes- 
tine moves  up  higher  and  thus  escapes  compression. 

The  small  intestine  receives  its  blood  supply  from  the 
abdominal  aorta.  The  arteria  gastroduodenalis,  a  branch 
of  the  arteria  hepatica,  supplies  the  upper  part  of  the  duo- 
denum ;  the  lower  part  of  the  duodenum  and  the  jejunum 
and  ileum  are  supplied  bj^  the  arteria  mesenterica  superior. 
The  latter  vessel  branches  off  into  a  fine  net  of  numerous 
small  vessels  which  run  through  the  intestinal  wall.  The 
end  ramifications  penetrate  the  submucosa  and  here  again 
form  a  net.  From  the  latter  the  finest  ramifications  pene- 
trate the  mucosa  and  form  a  capillar}-  system  of  the  villi 
and  glands.  The  venous  blood  flows  partly  into  the  vena 
gastrica  superior,  partly  into  the  vena  mesenterica  superior, 
and  empties  itself  into  the  vena  porta.     The  lymphatics 


6  DISEASES  OF  THE  INTESTINES. 

form  a  continuous  series  which  is  divided  into  two  sets, 
that  of  the  mucous  membrane  and  that  of  the  muscular 
coat.  The  lymph  vessels  of  both  sets  form  a  copious 
plexus.  They  run  between  the  two  folds  of  the  mesentery 
and  end  in  the  mesenteric  lacteals.  They  are  provided 
with  valves  which  prevent  the  current  from  flowing  back- 
ward, the  direction  of  which  is  into  the  truncus  lymphati- 
cus  intestinalis  and  finally  into  the  thoracic  duct. 

The  nerves  of  the  small  intestine  originate  principally 
from  the  plexus  mesentericus  superior  or  the  sympathetic. 
The  duodenum  is  supplied  by  the  plexus  hepaticus,  a 
branch  of  the  plexus  coeliacus.  The  abdominal  part  of  the 
vagus,  namely,  the  plexus  gastricus,  anterior  and  posterior, 
also  supplies  the  small  intestine  with  nerves.  The  nerves, 
which  are  mostly  non-medullary,  enter  the  intestinal  wall 
in  connection  with  the  branches  of  the  arteria  mesenterica 
superior  and  form  a  subserous  net.  They  then  penetrate 
the  long  muscular  fibres  and  form  between  these  and  the 
circular  muscular  fibres  ramifications  which  consist  of  nu- 
merous groups  of  multipolar  cells  (plexus  mesentericus 
seu  Auerbachii) ;  fine  branches  of  nerves  arising  here  sup- 
ply the  muscularis.  Others  penetrate  the  circularis,  reach 
the  submucosa,  and  form  the  submucous  nerve  plexus, 
containing  small  groups  of  ganglion  cells  (Meissner's  nerve 
plexus) ;  fine  ramifications  also  supply  the  muscularis  mu- 
cosae, the  muscles  of  the  villi,  and  end  in  the  remaining 
part  of  the  mucosa. 

Structure  of  the  Small  Intestine. 

The  small  intestine  is  composed  of  four  principal  coats : 
the  serous,  muscular,  submucous,  and  mucous  (Fig.  2). 
The  serous  coat  is  formed  by  the  visceral  layer  of  the  peri- 
toneum.    The  muscular  coat  consists  of  an  internal  circular 


ANATOMY. 


and  an  external  longitudinal  layer  (Fig.  3).     The  former 
is  usually  considerably  thicker  than  the  latter.     They  both 


Fig.  2.— Longitudinal  Cross-section  through  the  Wall  of  the  Small  Intestine  (Ileum). 
Solitary  lymph  nodules  (nodulus  lymphaticus  solitarius).  Intestinal  glands  (Lieber- 
kuehni)  (Toldt).  a.  The  mucous  layer ;  h.  the  muscularis  mucosae ;  c,  the  submucous 
layer ;  (/,  the  muscular  layer ;  c.  thesubserosa ;  /.  the  serous  layer ;  y,  intestinal  villi : 
h,  intestinal  glands  (Lieberkuehn)  ;  i.  blood-vessels ;  fc,  a  solitary  lymph  nodule ;  l,  its 
centre. 

consist  of  bundles  of  uustriped  muscular  tissue  supported 
by  connective  fibres.  The  submucous  coat  consists  of  con- 
nective tissue  in  which  numerous  blood-vessels  and  lym- 


FiG.  3.— Longitudinal  Cross-section  through  the  Wall  of  the  Duodenum.  Brunner's 
glands  (glanduUe  duodenales)  (Toldt).  a.  The  mucous  layer  ;  }>,  the  muscularis  muco- 
sae ;  c,  the  submucous  layer ;  (/,  the  circular  muscular  layer ;  e,  the  longitudinal  mus- 
cular layer ;  /,  intestinal  villi ;  :;,  intestinal  glands  (Lieberkuelm) ;  h,  Branner's  duo- 
denum glands ;  j,  serous  layer. 

phatics  ramify.     The  mucous  membrane  is  the  most  im- 
portant coat  with  regard  to  the  function  of  digestion.     It 


8 


DISEASES  OP  THE  INTESTINES. 


consists  of  a  very  thin  muscular  layer  (muscularis  mucosae) 
containing  circular  and  longitudinal  fibres,  the  tunica 
propria  of  the  mucosa,    a   tissue  made    up    principally 

of  reticular  connective 
tissue  with  numerous 
leucocytes,  glands,  and 
the  epithelial  covering. 
The  mucous  membrane 
of  the  small  intestine  is 
of  a  grayish-red  color 
and  has  a  velvety  ap- 
pearance. It  possesses 
certain  large  folds  of 
valvular  flaps  (valvulse 
conniventes  Kerkringi) 
(Fig.  4).  These  are" 
permanent  crescentic 
folds  of  mucous  mem- 
brane set  transversely 
to  the  long  axis  of  the 
intestine.  Each  one  ex- 
tends from  one-half  to  two-thirds  of  the  distance  of  the 
lumen.  The  largest  are  more  than  two  inches  long  and 
about  one-third  of  an  inch  wide.  They  begin  somewhat 
below  the  pylorus,  are  very  large  just  below  the  entrance 
of  the  bile  duct,  remain  conspicuous  until  the  middle  of 
the  jejunum  is  reached,  then  become  smaller  and  gradually 
disappear  at  the  lower  jjart  of  the  ileum.  They  serve  to 
increase  the  surface  of  the  mucous  membrane. 

The  microscopical  anatomy  of  the  mucous  membrane 
reveals  the  following :  The  entire  inner  surface  of  the  small 
intestine  is  composed  of  villi,  certain  papilliform  processes, 
and  glands ;  an  epithelial  layer  containing  columnar  epi- 


Fio.  4.— Jejunum  Partly  Opened  (Toldt).  a. 
Serosa ;  b,  mucosa :  c,  circular  folds  of  Ker- 
kring. 


ANATOMY. 


9 


thelial  cells  with  a  striated  border,  and  some  goblet  cells 
cover  the  entire  surface.  The  villi  are  formed  principally 
by  elevations  of  the  tunica  propria  of  the  mucous  mem- 
brane (Fig.  5).  They  are  about  0.5  to  0.7  mm.  in  height 
and  about  0.1  to  0.2  mm.  wide  and  number  almost  ten  mil- 
lions. Each  villus  possesses  a  centrallj^  located  space  for 
chyle  which  is  covered  with  endothelial  cells  and  connected 
with  the  lymphatics  of  the  intestinal  mucosa.  Each  villus 
contains  a  perfect  arrangement  of  blood-vessels  and  muscu- 
lar fibres  which  originate  in  the  muscularis  mucosae.  When 
filling  up  with  blood  each  villus  expands,  while  under  the 
contraction  of  its  muscle  it  shrinks.  Thus  it  is  enabled  to 
perform  the  function  of  suction  and  pumping.  The  villi 
form  the  main  organ  for 
the  absorption  in  the 
small  intestine. 

Around  the  villi  lie 
their  glands.  First, 
there  are  tubular  glands 
(of  Lieberkiihn),  and, 
secondly,  acinous  glands 
of  Brunner.  The  former 
are  similar  in  structure 
to  the  tubular  glands  in 
the  stomach.  They  cover 
almost  the  entire  surface 

of  the  whole  small  and  large  intestine.  Each  glandular 
tubule  is  about  0.3  to  0.4  mm.  long  and  opens  without 
forming  any  ramifications.  They  number  over  forty  mil- 
lions and  form  the  principal  organ  of  intestinal  secretion. 
Brunner's  glands  are  confined  to  the  duodenum.  They 
are  most  abundant  at  the  commencement  of  this  portion 
of  the  intestine,  diminishing  gradually  as  the  duodenum 


Fig.  5.— Mucous  Membrane  of  the  Ileum  with 
a  Solitary  Lymph  Nodule  (Toldt).  a.  In- 
testinal glands  (Lieberkuehn) :  b,  intestinal 
villi ;  c,  a  solitary  lymph  nodule. 


10 


DISEASES  OF  THE  INTESTINES. 


advances.  They  are  situated  beneath  the  mucous  mem- 
brane and  embedded  in  the  submucous  tissue.  Each 
gland  is  a  branched  and  convoluted  tube  lined  with  col- 
umnar epithelium.  In  structure  they  are  very  similar  to 
the  pyloric  glands  of  the  stomach,  but  are  more  branched 
and  convoluted,  and  their  ducts  are  longer.     The  duct  of 

each  gland  passes  through 
the  muscularis  raucosse 
and  opens  on  the  surface 
of  the  mucous  membrane. 
Solitary  follicles  or 
glands  are  found  scat- 
tered throughout  the  mu- 
cous membrane  of  the 
small  intestine.  They 
are  most  numerous  in  the 
lower  part  of  the  ileum. 
Each  one  has  a  diameter 
of  from  3  to  6  mm.  The 
structure  of  the  solitary 
follicle  is  similar  to  that 
of  the  lymph  nodes  and 
consists  of  a  dense  reti- 
form  tissue  packed  with 
lymph  corpuscles  and 
permeated  by  fine  capillaries.  There  are  no  ducts.  The 
interspaces  of  the  retiform  tissue  are  continuous  with  lar- 
ger lymph  spaces  at  the  base  of  the  gland,  by  which  they 
communicate  with  the  lacteal  system.  The  base  of  the 
nodules  is  in  the  submucous  tissue.  It  penetrates  the 
muscularis  mucosae  and  enters  the  mucous  membrane  form- 
ing a  slight  projection  of  its  epithelial  layer.  The  solitary 
follicles  are  the  breeding  place  of  the  lymph  cells.     They 


Fig.  ti.— Ileum  Partly  Opt-ned  (Toldt).  a. 
Solitary  lymph  nodules;  h,  serosa;  e, 
mucosa. 


ANATOMY. 


11 


are  met  with  in  two  conditions,  namely,  either  scattered 
singly,  in  which  case  they  are  termed  glandulse  solitarijB 
(Fig.  6),  or  aggregated  in  groups  varying  from  one  to  three 


:^  "*■ 


FiG.  7.— Peyer's  Patch  (Nodull  Lymphatic!  Aggrejfati)  In  the  Ileum  (Toldt).    ct,  Peyer's 
patch  ;  h,  solitary  lymph  nodules. 

inches  in  length  and  about  one-half  inch  in  width.  The 
surface  of  the  solitary  follicles  is  free  from  villi.  Chiefly 
of  an  oval  form,  their  long  axis  is  i:)arallel  with  that  of  the 
intestine.  In  this  state  they  are  called  glandulte  agminatsB 
or  Peyer's  patches  or  plaques  (Fig.  7).  They  are  almost 
always  placed  opposite  the  attachment  of  the  mesenter}'. 
Peyer's  patches  number  about  twent}'  to  twentj'-eight.  In 
some  cases  they  are  already  found  in  the  jejunum,  but 
they  are  most  prevalent  in  the  ileum. 


The  Large  Intestine  or  Large  Bowel  (Intestinum  Crassum). 

The  large  intestine  extends  from  the  termination  of  the 
ileum  to  the  anus.  It  is  about  five  to  six  feet  in  length. 
Its  calibre  decreases  from  beginning  to  end  except  at  the 
ampulla  of  the  rectum  where  it  is  larger.  It  measures 
28.5  cm.  in  circumference  at  the  junction  of  colon  and  csb- 


12 


DISEASES  OF  THE  INTESTINES. 


cum,  20.5  cm.  at  the  end  of  the  ascending  portion,  14.5  cm. 
in  the  descending  portion.  The  large  intestine  is  divided 
into  the  caecum,  colon,  and  rectum.     With  the  exception 

of  the  rectum 
it  possesses 
three  taeniae, 
these  being 
groups  of  non- 
striated  muscu- 
lar fibres  run- 
ning lengthwise 
with  the  lumen 
of  the  intestine. 
Between  the 
taeniae  the  walls 
are  somewhat 
sacculated.  The 
circular  muscu- 
lar ti  b  r  e  s  are 
also  accumulat- 
ed in  spots, 
leaving  short 
intervals  be- 
t  w  e  e  n  each 
other,  thus 
forming  c  o  n  - 
strictions  and 
expansions  (haustra  coli)  across  the  intestiue  (Fig.  8). 
The  large  bowfel  is  further  characterized  by  appendices 
epiploicae,  external  pouches,  formed  by  the  peritoneal  cov- 
ering containing  fat.  The  caecum  is  the  head  of  the  colon 
or  that  part  of  the  large  bowel  situated  below  the  mouth  of 
the  ileum  (Fig.  9).     It  lies  in  the  right  iliac  fossa  and  is 


Fio.  8.— The  Large  Bowel  Partly  Opened  along  the  Mesen- 
tery (Toldt).  a.  Free  taenia:  />.  ttenla  mesocolica;  c. 
appendices  eplploicse ;  d,  tbe  mucosa ;  e,  the  semllunar 
folds  of  the  colon ;  /,  the  mesocolon. 


ANATOMY. 


13 


completely  covered  by  the  peritoneum.  In  the  filled  con- 
dition it  touches  the  anterior  abdominal  wall.  Starting 
from  the  inner  and  back  portion  of  the  caecum  lies  the  pro- 
cessus vermiformis  or  appendix,  forming  a  narrow,  some- 
what bent,  blind-ending  tube.  The  appendix  is  movable 
and  has  its  own  ^ 

mesentery  (mes-  p, 

enteriolum). 
Its  length  varies 
between  2  and  20 
cm .  and  its 
width  between 
0.5  and  1  cm. 
The  appendix 
opens  into  the 
CFBCum  (ostium 
processus  vermi- 
formis), occa- 
sionally form- 
ing a  crescentic 
fold  (v  a  1 V  u  1  a 
processus  v  e  r - 
miformis).  In 
man  it  consti- 
tutes an  entirelj^ 
functionless  or- 
gan which  occa- 
sionally gives 
rise  to  manifold 

ailments.      The  appendix  has  no  fixed  position.     J.    D. 
Bryant'  found  it  most  often  "inward,"  then  "behind  the 
caecum,"  "downward  and  inward,"  "into  the  true  pelvis." 
"  J.  D.  Bryant :  Annals  of  Surgery,  February,  1893,  p.  164. 


Fig.  9.— Section  of  the  Caecum  and  Ileum,  showing  the  En- 
trance of  the  Latter  Into  the  Caecum  (Toldt).  o,  The 
semilunar  folds  of  the  colon ;  b,  c,  the  lleocaecal  valves  (b, 
the  upper,  and  c.  the  lower  one) ;  d,  the  end  portion  of 
the  Ileum ;  c.  the  posterior  lleocaecal  valve ;  /,  the  appen- 
dicular valve;  y,  the  appendix. 


14  DISEASES  OF  THE  INTESTINES. 

Without  distinct  demarcation  the  caecum  merges  into  the 
ascending  colon.  It  passes  vertically  above  the  crest  of 
the  ileum  and  runs  along  the  posterior  abdominal  muscles 
and  the  lower  part  of  the  right  kidney.  At  this  point  just 
in  front  of  the  kidney  and  immediately  beneath  the  liver 
the  colon  bends  toward  the  left  of  the  flexura  coli  dextra. 
The  ascending  colon  is  posteriorly  adherent  through  con- 
nective tissue  with  the  parts  just  mentioned,  while  the 
peritoneum  covers  only  its  anterior  and  partly  also  its  lat- 
eral surfaces.  In  close  proximity  to  its  median  wall  lies 
the  ascending  part  of  the  duodenum.  Beginning  at  the 
flexura  coli  dextra  the  colon  runs  across  the  abdominal 
cavity  from  right  to  left  (transverse  colon),  forming  the 
longest  segment  of  the  large  intestine.  It  passes  from  the 
hepatic  flexure  in  the  right  hypochondrium  transversely 
and  slightlj'  upward  from  right  to  left  along  the  anterior 
abdominal  wall  to  the  splenic  flexure  in  the  left  hypochon- 
drium. This  part  of  the  colon  is  the  most  movable.  It 
has  a  very  long  mesentery,  called  the  transverse  meso- 
colon. The  usual  position  of  the  transverse  colon  corre- 
sponds to  a  line  separating  the  umbilical  and  epigastric 
regions.  It  is  in  relation  by  its  upper  surface  with  the 
lower  part  of  the  liver  and  gall  bladder,  the  greater  curva- 
ture of  the  stomach  and  the  lower  end  of  the  spleen ;  by 
its  under  surface  with  the  small  intestine ;  by  its  anterior 
surface  with  the  great  omentum  and  abdominal  wall;  by 
its  posterior  surface  with  the  transverse  mesocolon ;  on  the 
right  side  with  the  second  part  of  the  duodenum,  and  on 
the  left  besides  the  latter  with  some  convolutions  of  the 
small  intestine. 

The  transverse  colon  does  not  form  a  straight  line  con- 
necting the  right  and  left  flexures,  but  is  about  twice  as 
long  as  this  line  and  therefore  forms  several  curves.     In 


ANATOMY.  IJ 

the  left  hypochondrium  especially,  there  is  an  S-shaped 
coil.  The  latter  tills  out  the  free  space  in  the  left  hypo- 
chondrium -.vhich  is  left  by  the  stomach  in  its  various 
states  of  fuluess.  Beginning  at  the  flexura  coli  sinistra 
the  descending  colon  runs  downward  in  front  of  the  left 
kidney  and  the  quadratus  lumborum  and  iliac  muscles  un- 
til it  reaches  the  left  iliac  fossa.  The  descending  colon 
runs  just  in  the  opjjosite  direction  to  the  ascending  colon, 
and  like  this  is  only  partly  covered  by  the  peritoneum. 
The  descending  colon  passes  into  the  sigmoid  colon  or 
flexure  (S  Romanum),  commencing  above  the  iliac  crest 
and  ending  below  in  the  rectum  at  the  brim  of  the  true 
pelvis  opposite  the  left  sacro-iliac  articulation.  It  is  gen- 
erally described  as  an  S-shaped  curve  having  an  upper 
colic  rim  turned  toward  Poupart's  ligament  and  the  lower 
rectal  rim,  hanging  down  into  the  true  pelvis.  It  has  a 
complete  peritoneal  covering  or  mesentery.  This  part  of 
the  bowel  is  very  movable,  and  its  calibre  is  the  narrowest 
of  that  of  the  large  bowel.  The  sigmoid  flexure  continues 
into  the  rectum,  forming  the  terminal  portion  cf  the  intes- 
tinal tube.  It  runs,  coming  from  the  left,  in  front  of  the 
OS  sacrum  down  to  the  bottom  of  the  small  pelvis.  Only 
the  upper  half  of  the  rectum  is  invested  completely  with 
peritoneum  (mesorectum)  and  is  attached  to  the  sacral  ver- 
tebra. The  lower  half  passes  between  the  organs  occupy- 
ing the  jjelvic  floor,  being  adherent  to  them  by  connective 
tissue.  It  now  runs  posteriorly  along  the  os  coccjx  and 
terminates  in  the  anus.  This  part  has  an  incomplete  peri- 
toneal covering  (plica  Douglasii)  lying  anteriorly  and  turn- 
ing backward  in  order  to  ascend  either  over  the  vagina  or 
the  bladder  (excavatio  recto-uterina,  excavatio  rectovesica- 
lis).  Below  this  point  the  rectum  has  very  little  mobility 
as  it  is  covered  all  around  by  connective  tissue.     The  en- 


16  DISEASES  OF  THE  INTESTINES. 

tire  rectum  is  about  18  to  22  cm.  long.  Its  calibre  varies. 
It  is  widest  at  the  apex  of  the  prostate,  forming  the  am- 
pulla of  the  rectum. 

The  longitudinal  muscular  fibres  of  the  rectum  are  not 
arranged  in  tseniae  as  in  the  colon,  but  pass  all  around  the 
lumen.  The  circular  muscular  fibres  become  more  dense 
from  above  downward  and  increase  to  such  a  degree  at  the 
anal  opening  that  they  here  form  a  thick  ring  (musculus 
sphincter  ani  intemus).  A  short  distance  above  this  mus- 
cle there  is  also  an  accumulation  of  circular  muscular  fibres 
(musculus  sphincter  ani  tertius).  At  the  anus  the  walls  of 
the  rectum  are  connected  with  striated  muscular  fibres 
(sphincter  ani  extemus  and  levator  ani),  which  are  both 
of  importance  in  the  act  of  defecation. 

The  colon  is  supplied  by  the  three  arteriae  colicje, 
branches  of  the  arteria  mesenterica  superior  and  arteria 
mesenterica  inferior.  The  arteria  colica  sinistra  origi- 
nates from  the  arteria  mesenterica  inferior,  while  the  ar- 
teria colica  media  and  superior  are  tributaries  of  the  arteria 
mesenterica  superior.  The  veins  accompany  the  artery  and 
empty  partly  into  the  vena  mesenterica  superior,  partly 
into  the  vena  mesenterica  inferior.  The  lymphatics  of  the 
colon  are  numerous  and  lie  below  the  glands  and  all 
through  the  submucosa.  The  plexus  mesentericus  supe- 
rior, a  branch  of  the  plexus  coeliacus,  provides  the  nervous 
supply  of  the  caecum,  ascending  colon,  and  the  right  half 
of  the  transverse  colon.  The  plexus  mesentericus  inferior, 
a  branch  of  the  plexus  aorticus  abdominalis,  supplies  the 
left  half  of  the  transverse  colon,  the  descending  colon,  and 
the  sigmoid  flexure. 

The  rectum  is  supplied  by  the  arteriae  haemorrhoidales 
superior,  media,  and  inferiores,  branches  of  the  arteria 
mesenterica  inferior  and  arteria  pudenda  communis.     The 


ANATOMY.  17 

venous  blood  of  tlie  rectum  is  carried  to  the  vensB  haeinor- 
rhoidales  principally  into  the  vena  mesenterica  inferior, 
thus  emptying  into  the  vena  portarum,  partly,  however, 
into  the  vena  iliaca  interna.  In  this  way  there  is  a  sepa- 
rate communication  (outside  of  the  portal  circulation)  with 
the  remaining  vessels  of  the  abdomen.  The  lymphatics  of 
the  rectum  form  a  wide  net,  running  partly  to  the  glands 
lying  behind  the  rectum,  partly  to  the  plexus  lumbalis 
sinister.  The  neyves  supplying  the  rectum  originate  from 
the  sympathetic,  being  branches  of  the  plexus  mesenteri- 
cus  inferior,  the  plexus  sacralis  (nervi  hsemorrhoidales  in- 
ferior and  medii),  and  the  plexus  hypogastricus  superior. 

Histology  of  the  Large  Bowel. 

The  large  bowel  consists,  like  the  small  bowel,  of  four 
coats:  the  serosa,  muscularis,  submucosa,  and  mucosa. 
The  structure  "of  these  four  coats  corresponds  to  that  of 
the  small  intestine,  except  that  the  longitudinal  muscular 
fibres  are  arranged  in  three  groups  (taenisB)  running  along 
the  wall,  as  mentioned  above.  The  mucosa  of  the  large 
bowel  differs  from  that  of  the  small  intestine  in  that  there 
is  an  absence  of  the  folds  of  Kerkring  and  of  the  villi. 
Lieberkiihn's  glands  are  here  somewhat  longer  and  some- 
times curved. 

The  mucous  membrane  of  the  rectum  is  thicker,  more 
red,  and  succulent  than  that  of  the  colon.  There  are  nu- 
merous folds.  One  conspicuous  fold  is  found  6  to  7  cm, 
above  the  anus  (plica  trans versalis  recti).  In  the  neigh- 
borhood of  the  anus  the  folds  take  a  longitudinal  direc- 
tion, and  are  called  columns  Morgagnii  seu  recti.  The 
lower  region  of  the  rectum  contains  the  epithelial  cells  of 
the  rectum,  pavement-like  epithelium,  forming  a  gradual 


18  DISEASES  OF  THE  INTESTINES. 

transition  from  the  mucous  membrane  of  the  digestive 
tract  to  that  of  the  external  skin.  The  upper  portion  of 
the  rectum  corresponds  exactly  to  that  of  the  colon. 

PHYSIOLOGY. 

The  intestines  are  entrusted  with  the  important  office  of 
digesting  the  food  which  has  not  been  acted  upon  by  the 
stomach,  of  absorbing  it,  and  finally  of  eliminating  the 
undigested  remnants.  In  order  to  fulfil  this  object  they 
have  three  functions,  the  secretory,  absorbent,  and  motor. 
All  these  functions  are  supervised  by  ganglionic  cells  and 
nerves,  the  latter  also  transmitting  sensory  impressions. 

1.   The  Secretory  Function  or  the  Chemical  Processes  in  the 

Intestines. 

As  is  well  known,  the  intestinal  secretion  consists,  first, 
of  the  bile ;  secondly,  the  pancreatic  juice ;  and  thirdly,  the 
intestinal  juice  proper  (succus  entericus).  The  composi- 
tion of  each  of  these  and  their  properties  may  be  found  in 
the  text-books  on  physiology,  and  also  briefly  in  my  book 
on  "The  Diseases  of  the  Stomach."  It  will  not  be  amiss, 
however,  to  describe  here  more  fully  their  joint  action  in 
the  intestinal  canal. 

The  effect  of  each  of  the  digestive  juices  is  influenced  by 
that  of  the  others.  For  this  reason  the  chemical  processes 
in  the  intestines  are  quite  complicated.  The  carbohy- 
drates, whose  conversion  into  maltose  by  the  ptyalin  has 
been  checked  in  the  stomach  by  the  free  hydrochloric  acid, 
are  now,  after  reaching  the  intestines,  further  changed  by 
the  diastase  of  the  pancreatic  secretion  into  maltose,  which 
is  further  converted  into  glucose.  Cane  sugar  is  likewise 
converted  into  grape  sugar,  while  milk  sugar,  according  to 


PHYSIOLOGY.  19 

Voit  and  Lusk,'  remains  unchanged.  The  finer  parts  of 
the  cellulose  also  undergo  some  changes,  but  their  ulti- 
mate products  are  not  known.  It  is  certain,  however,  that 
under  the  influence  of  micro-organisms  they  partly  undergo 
fermentation,  giving  rise  to  the  formation  of  marsh  gas, 
acetic  acid,  and  butyric  acid. 

The  pancreatic  juice  forms  the  principal  factor  of  all  the 
digestive  processes  in  the  intestinal  canal.  Besides  its  ac- 
tion upon  the  carbohydrates  through  its  diastatic  ferment, 
it  acts  upon  fats  by  means  of  the  steapsin  and  upon  al- 
buminates by  means  of  the  trypsin  ferment.  According 
to  Nencki  ^  and  Rachf ord,  ^  the  fat-splitting  action  of  the 
pancreas  is  greatly  increased  by  the  presence  of  bile.  The 
splitting  of  the  fats  into  fatty  acids  and  glycerin  is  of 
greatest  importance  for  absorption.  The  fatty  acids  com- 
bine with  the  alkalies  of  the  intestinal  and  pancreatic 
juices  and  form  soaps  which  are  either  absorbed  as  such 
or  promote  the  absorption  of  fats.  There  is  no  doubt 
that  the  greater  amount  of  fats  taken  in  with  the  nourish- 
ment is  absorbed  as  a  fine  emulsion  in  the  formation  of 
which  the  soaps  take  i)art.  These  processes  of  fat  emulsi- 
fication,  by  the  action  either  of  the  pancreatic  juice  or  of 
soaps,  take  place  only  in  alkaline  media.  If  the  intestinal 
contents  are  acid,  emulsification  does  not  occur,  or  does  so 
only  at  those  places  at  which  the  fat  comes  in  contact  with 
an  alkaline  secretion  covering  the  mucous  membrane.  Ac- 
cording to  Claude  Bernard  ^  and  Dastre, "  the  action  of  bile 
greatly  increases  the  emulsifying  property  of  the  pancre- 

'  Lusk  :  Zeitschr.  f.  Biologie.  Bd.  28.  p.  275. 
'•*  Nencki  :  Arch.  f.  experimentelle  Path.  u.  Pharm.,  Bd.  20. 
^  Racliford  •  Journal  of  Pliysiology,  vol.  12. 

■•  Claude  Bernard  :  "  Le9ons  de  physiologic  experimentale,  "  2d  edi- 
tion. 1865. 
'  Dastre  :  Arch,  de  Physiologic,  Tome  2,  p.  315. 


20  DISEASES  OF  THE  INTESTINES. 

atic  juice.  While  the  bile  exerts  a  deleterious  influence 
upon  the  action  of  jjepsin  in  artificial  solutions,  its  pres- 
ence in  the  stomach  does  not  seem  to  have  any  inhibitory 
effect.  The  bile  exerts  an  influence  upon  the  digestion  of 
the  albuminates  in  the  intestines  bj'  precipitating  the  pep- 
sin in  tho  acid  gastric  contents.  It  thus  destroys  the  ac- 
tion of  the  pepsin.  This  precipitate,  formed  by  the  gas- 
tric contents  and  the  bile,  is  soon  dissolved,  partly  through 
the  intervention  of  freshly  secreted  bile  in  abundance, 
partly  through  the  sodium  chloride  which  arises  after  the 
neutralization  of  the  gastric  juice  by  the  alkalies  present. 
The  action  of  the  bile  upon  the  pancreatic  digestion  of  al- 
bumin is  not  deleterious,  and  may  have  a  beneficial  effect 
in  the  presence  of  organic  acids  which,  as  a  rule,  exist  in 
the  upper  parts  of  the  small  intestine. 

Aside  from  the  chemical  processes  caused  bj-^  the  enzymes 
in  the  intestines  there  also  exist  fermentative  and  putre- 
factive changes  produced  hj  micro-organisms.  These  are 
but  very  slight  in  the  upper  part  of  the  intestine  and 
increase  in  intensity  toward  the  end  of  the  small  intestine 
and  in  the  greater  part  of  the  large  bowel,  while  they  again 
decrease  in  the  lower  part  of  the  bowel  and  in  the  rectum. 
According  to  Macfadyen,  Nencki,  and  Sieber,*  who  have 
repeatedly  analyzed  the  intestinal  contents  of  a  man  with 
a  fistula  situated  near  the  end  of  the  ileum,  only  fermen- 
tative processes  take  place  within  the  small  intestine.  The 
contents  obtained  in  this  case  had  a  golden-yellow  color 
and  showed  an  acid  reaction,  the  acidity  amounting  to  one 
per  mille.  As  a  rule,  they  were  odorless.  The  principal 
elements  of  the  acidity  consisted  of  acetic,  lactic,  and 
paralactic  acids,  volatile  fatty  acids,  succinic  acid,  and 

'  Macfadyen,  M.  Nencki  und  N.  Sieber :  Arch.  f.  experimentelle 
Pathol,  u.  Pharm.,  Bd.  28,  p.  311. 


PHYSIOLOGY.  21 

biliary  acids;  albumin,  peptone,  mucin,  dextrin,  sugar, 
and  alcohol  were  i^resent;  leucin  and  tyrosin,  however, 
were  absent.  Thus,  according  to  these  authors,  fermenta- 
tive jirocesses  in  the  small  intestine  result  merely  from 
the  action  of  microbes  upon  carbohydrates,  which  ac- 
tion ultimately  leads  to  the  formation  of  ethyl  alcohol 
and  the  organic  acids  just  mentioned.  The  latter  pre- 
vent the  putrefaction  of  albuminates  within  the  small  in- 
testine and  also  partly  check  the  decomposition  of  the 
carbohydrates. 

The  putrefaction  of  the  albuminates  takes  i^lace  in  the 
large  intestine,  the  contents  there  having  an  alkaline  reac- 
tion. The  decomposition  of  the  albuminates  by  the  putre- 
factive processes  caused  by  micro-organisms  goes  much 
further  than  that  by  the  pancreatic  digestion.  The  pan- 
creatic digestion  of  the  albuminates  gives  rise  to  albumoses 
and  peptones,  lysin,  lysatinin,  proteinchromogeu,  amido- 
acids,  and  ammonia.  In  the  jiutrefaction  of  the  albumin- 
ates at  first  the  same  products  are  formed,  but  the  decom- 
position advances  still  further  and  generates  a  host  of  new 
products:  indol,  skatol,  i)ai-acresol,  phenol,  phenyl-propi- 
onic acid  and  phenyl-acetic  acid,  para-oxyphenyl-acetic 
acid,  hydroparacumaric  acid,  volatile  iat\y  acids,  carbon 
dioxide,  hydrogen,  marsh  gas,  methyl  mercaptan,  and  sul- 
phuretted hydrogen.  In  the  putrefaction  of  gluten  neither 
tyrosin  nor  indol  is  formed  while  glycocoll  is  developed. 
Of  the  products  of  decomposition  just  named  some  are  of 
great  importance,  as  they  are  eliminated  by  way  of  the  urine 
after  their  absorption  from  the  intestinal  wall.  Some  of 
them,  as  for  instance  the  oxy-acids,  appear  unchanged  in 
the  urine,  others  (like  the  phenols)  after  further  oxidation, 
and  still  others  (like  indol  and  skatol)  after  combination 
with  ethereal  sulphuric  acids.     The  presence  of  ethereal 


22  DISEASES  OF  THE  INTESTINES. 

sulphuric  acids  in  the  urine  is  thus  to  a  certain  extent  an 
indication  of  the  amount  of  putrefaction  going  on  in  the 
intestine.  The  putrefactive  processes  in  the  intestine  relate 
not  only  to  the  ingested  food  but  also  to  the  secretions 
rich  in  albuminates.  Thus  Miiller  '  observed  that  Cetti 
during  his  fasting  period  first  showed  a  diminution  of  the 
amount  of  indican  in  the  urine  which  entirely  disappeared 
on  the  third  day.  The  phenol  elimination  was  also  at  first 
diminished,  but  beginning  from  the  fifth  day  of  fasting  it 
commenced  to  increase,  and  on  the  eighth  or  ninth  day 
reached  an  amount  which  was  three  to  seven  times  that  of 
a  man  under  ordinary  conditions. 

The  putrefactive  processes  within  the  intestines,  how- 
ever, do  not  reach  that  height  which  they  attain  outside 
of  the  body.  Thus,  for  instance,  the  fresh  contents  of  the 
large  bowel  do  not  present  so  fetid  an  odor  as  a  pancreatic 
infusion  or  decomposing  albumin  would  reveal  after  long 
standing.  The  putrefaction  within  the  intestine  is  partly 
checked  by  several  factors : 

1.  Carbohydrates  as  such  exert  an  inhibitory  influence 
upon  putrefaction  (Hirschler'');  the  organic  acids  which 
develop  during  their  fermentation  also  partly  check  putre- 
faction. Of  other  foods,  milk  and  kumyss,  according  to 
Schmitz,"  likewise  lessen  the  processes  of  bacterial  de- 
composition, this  effect  being  due  to  the  presence  of  lactose 
and  also  of  lactic  acid. 

2.  The  bile  exerts  a  decidedly  anti-putrefactive  action. 
As  shown  by  Liudberger '  and  Limbourg, "  albumin  to 
which  bile  is  added  does  not  decompose  so  thoroughly  as 

'  MtlUer:  Berl.  kiln.  Wochenschr.,  1887,  No.  24. 

»  Hirschler :  Zeitachr.  f.  physiol.  Chemie,  Bd.  10.  p.  306. 

3  Schmitz :  2Jeit8chr.  f.  physiol.  Chemie,  Bd.  17,  p.  401. 

*Lindberger:  Maly's  Jahresber..  Bd.  14,  p.  334. 

*  Limbourg  :  Zeitschr.  f.  physiol.  Chemie,  Bd.  13. 


PHYSIOLOGY.  23 

without  it.  The  biliary  acids,  moreover,  inhibit  putrefac- 
tion through  their  acid  elements. 

3.  Absorption.  The  rapid  absorption  of  fluids  from  the 
intestinal  wall  and  the  forward  motion  of  the  contents  do 
not  permit  the  putrefactive  processes  to  get  the  upper  hand. 

These  fermentative  and  putrefactive  processes  taking 
place  within  the  intestines  serve  to  augment  the  various 
means  at  the  disposal  of  the  organism  to  utilize  or  to  break 
up  into  simpler  components  the  more  complex  groups  of 
various  food  substances.  In  the  normal  state  these  putre- 
factive processes  are  most  j^robably  checked  before  any 
deleterious  substances  can  be  developed. 

The  intestinal  contents  on  their  long  way  from  the  duo- 
denum to  the  anus  show  the  presence  of  different  gases. 
These  consist  of  traces  of  oxygen  and  a  larger  amount  of 
nitrogen ;  the  latter  is  derived  either  from  swallowed  air 
which  has  come  from  the  stomach,  or  from  pure  nitrogen 
which  has  been  diffused  from  the  tissues  through  the  in- 
testinal walls.  Carbonic-acid  gas  is  present  which  has  been 
developed  through  neutralization  of  the  acid  gastric  con- 
tents by  the  pancreatic  and  intestinal  juices,  and  also  from 
the  butyric  and  lactic  acid  fermentation  of  the  carbohy- 
drates. Hydrogen  is  found  in  larger  amounts  after  a  milk 
diet  and  only  in  small  quantities  after  a  pure  meat  diet. 
Methyl  mercaptan  and  sulphuretted  hydrogen  are  present 
in  traces,  and  undoubtedly  owe  their  origin  to  the  albumin. 
MarslV  gas  likewise  results  from  the  decomposition  of 
albumin,  but  it  is  also  evolved  from  the  fermentation  of 
carbohydrates,  especially  of  cellulose.  These  different 
gases  are  formed  and  absorbed  all  along  the  intestinal 
walls,  and  most  probably  help  to  mix  the  contents  and 
thus  facilitate  absorption.  If  present  in  too  large  quanti- 
ties, they  are  easily  passed  through  the  rectum ;  occasion- 


24  DISEASES  OF  THE  INTESTINES. 

ally  some  of  the  gases  contained  in  the  upper  part  of  the 
small  intestine  may  be  eructated  by  way  of  the  stomach 
through  the  mouth. 

In  passing  through  the  large  bowel  the  intestinal  con- 
tents become  thickened  through  the  rapid  absorption  of 
the  fluids,  and  at  last  are  eliminated  as  fecal  matter.  This 
(faeces)  comprises  the  remnants  of  the  undigested  material, 
excretory  products  of  the  intestines,  and  a  host  of  micro- 
organisms. The  quantity  of  fecal  matter  within  twenty- 
four  hours  varies  greatly  according  to  the  mode  of  nourish- 
ment. Thus  after  a  mixed  diet  it  amounts  usually  to  from 
120  to  150  gm.  After  a  vegetable  diet,  however,  the  quan- 
tity, according  to  Voit,'  reached  333  gm.  The  reaction  of 
the  faeces  is  varied.  Often  it  is  found  acid  in  their  inner 
parts,  while  the  outer  surface  shows  an  alkaline  reaction. 
Their  peculiar  odor  is  principally  due  to  Brieger's  skatol, 
but*  also  to  indol  and  other  substances.  Their  color  is 
usually  of  a  light  or  dark  brown,  according  to  the  charac- 
ter of  the  nourishment. 

2.  Absorption. 

The  object  of  digestion  is  to  dissolve  and  partially 
change  the  food  substances  into  such  combinations  as  can 
be  assimilated  by  the  blood.  Before  assimilation  can  be 
effected  absorption  must  take  place.  The  main  place  for 
the  absorption  of  nutritive  material  is  the  small  intestine. 
It  will  be  best  to  describe  the  process  of  absorption  of  the 
different  food  materials  separately. 

(o)  The  proteids  are  usually  changed  into  albumoses 

and  peptones  before  their  absorption.     Albumen  as  such, 

however,  is  also  liable  to  be  absorbed,  although  not  so 

quickly  as  when  its  change  into  peptone  has  been  accom- 

'  Voit:  Zeitschr.  f.  physiol.  Chemie,  Bd.  13. 


PHYSIOLOGY.  25 

plished.  The  absorption  of  albumoses  and  peptones  takes 
place  through  the  intestinal  wall  b}^  way  of  the  capillaries 
of  the  blood-vessels  and  not  through  the  lacteals.  Thus 
Munk  and  Rosenstein  '  observed  in  a  patient  with  a  lymph 
fistula  that  after  a  meal  rich  in  albuminous  food  the  lymph 
did  not  contain  more  proteids  than  before  the  meal.  The 
peptones  and  albumoses  do  not  reach  the  blood  current  as 
such,  but  are  previously  reconverted  into  albumin.  This 
fact  has  been  clearly  shown  by  the  experiments  of  Ludwig 
and  Salvioli.^  These  investigators  tied  a  resected  intesti- 
nal coil  at  both  ends  and  injected  into  its  lumen  a  solution 
of  peptone,  while  the  coil  was  kept  alive  with  defibrinated 
blood.  Although  the  peptone  entirely  disappeared  from 
the  intestinal  coil,  the  blood  did  not  contain  even  traces 
of  peptone.  It  therefore  must  have  become  changed  into 
another  substance.  This  change  of  the  peptones  into  al- 
buminates before  reaching  the  blood  is  of  teleological  im- 
portance. For,  as  has  been  shown  by  Schmidt-Miihlheim' 
and  others,  peptone  introduced  into  the  circulating  blood 
is  soon  eliminated  with  the  urine.  Where  the  change  of 
the  peptones  into  albuminates  takes  place  and  by  what 
mechanism  are  not  as  yet  certain.  Some  seem  to  believei 
that  the  epithelial  cells  of  the  intestinal  walls  perform  this 
office,  others  that  the  leucocytes  are  the  means  of  its  con- 
version. 

The  absorption  of  the  albuminates  appears  to  be  more 
complete  as  regards  animal  than  vegetable  food.  The 
reason  for  this  is  that  the  cellulose  surrounding  the  legu- 
men  partly  renders  its  absorption  more  difficult.  Again, 
the  peristalsis  being  greater  after  vegetable  food,  the  intes- 

•  Munk  and  Rosenstein  :  Virchow's  Arch.,  Bd.  123. 

"  Lndwig  and  Salvioli :  Du  Bois-Reymond's  Arch.,  1880,  Suppl. 

8  Schmidt-Mtihlheim  :  Du  Bois-Reymond's  Arch.,  1880. 


26  DISEASES  OP  THE  INTESTINES. 

tinal  contents  pass  through  the  canal  quicker,  and  thus 
less  of  the  albumen  is  utilized.  And  again,  according  to 
Hammarsten, '  a  part  of  the  nitrogenous  substances  of  the 
plant  proteids  a})pears  to  be  indigestible. 

(b)  The  carbohydrates  are  absorbed  principally  as  mono- 
saccharides. Glucose,  Isevulose,  and  galactose  are  absorbed 
as  such.  Cane  sugar  and  maltose  are  ordinarily  changed 
first  into  glucose  and  Isevulose.  According  to  Voit  and 
Lusk,  sugar  of  milk  is  not  converted,  and  is  either  partly 
absorbed  as  such  or  else  undergoes  lactic-acid  fermenta- 
tion. The  different  kinds  of  sugar  are  absorbed  through 
the  capillaries  of  the  villi  and  thus  reach  the  circulation. 
They  enter  the  liver  through  the  vena  porta  and  are  here 
retained  in  great  part  as  glycogen.  In  case,  however,  a 
large  quantity  of  sugar  is  at  once  absorbed,  it  may  occa- 
sionally reach  the  lacteals  and  thus  enter  the  blood  current 
outside  of  the  liver.  In  such  instances  sugar  appears  in 
the  urine,  a  condition  which  is  known  as  alimentary  glyco- 
suria. The  introduction  of  larger  quantities  of  sugar  into 
the  intestinal  tract  occasionally  gives  rise  to  diarrhoea. 
Carbohydrates,  however,  even  in  large  amounts  in  the  form 
of  starch,  will  be  absorbed  without  difficulty  and  without 
giving  rise.to  any  trouble. 

(c)  The  fats.  In  the  absorption  of  fats  their  emulsifica- 
tion  seems  to  be  of  greatest  importance.  Although  a  small 
part  is  absorbed  in  the  form  of  soaps,  the  greatest  quan- 
tity of  fat  is  taken  up  in  the  form  of  an  emulsion.  The 
latter  comprises  not  only  neutral  fats  but  also  fatty  acids. 
These,  however,  undergo  a  change  into  neutral  fats  after 
their  absorption  from  the  intestinal  walls.  It  is  generally 
accepted  that  fats  after  their  absorption  from  the  intestinal 

'  Olof  Hammarsten  :  "  Lehrbuch  der  pbysiologischen  Chemie, "  Wies- 
baden, 1895,  p.  293. 


PHYSIOLOGY.  27 

wall  directly  reach  the  lymphatics  and  thus  enter  the  tho- 
racic duct,  whence  they  afterward  find  their  way  into  the 
blood  current.  In  a  girl  with  a  lymph  fistula  Munk  and 
Rosenstein  found  that  sixtj-  per  cent  of  the  ingested  fat 
appeared  in  the  lymph.  After  giving  the  patient  erucic 
acid  (a  fatty  acid  foreign  to  the  organism)  they  could  dis- 
cover thirty-seven  per  cent  of  this  particular  substance  in 
the  form  of  neutral  fats.  Thus  it  appears  to  be  proven 
that  while  the  proteids  and  carbohydrates  after  their  ab- 
sorption directly  reach  the  blood  current,  as  mentioned 
above,  the  fats  are  an  exception  and  directly  enter  the  lac- 
teals.  The  ultimate  way  in  which  absorption  takes  place 
is  not  as  yet  known.  It  must,  however,  be  accepted  that 
the  epithelial  cells  of  the  intestinal  wall  cause  this  process 
by  some  specific  action.  The  absorptive  property  of  the 
small  intestine  for  fat  is  very  great.  According  to  Rub- 
ner,'  a  man  can  absorb  over  300  gm.  of  fat  per  day.  Not 
all  kinds  of  fat,  however,  have  the  same  coefficient  of  as- 
similation. Thus  fats  with  a  low  melting-point  (olive  oil, 
goose  fat,  butter,  etc.)  are  absorbed  more  quickly  than 
those  Avith  a  high  melting-point  (mutton  fat  and  stearin). 
Moreover,  free  fats,  like  butter  and  lard,  are  assimilated 
more  quickly  and  thoroughly  than  bacon,  in  which  the  fat 
is  surrounded  by  connective  tissue. 

Besides  the  above-named  three  groups  of  food  sub- 
stances, water  and  different  salts  which  are  kept  in  solu- 
tion are  very  quickly  and  thoroughly  absorbed  all  along 
the  intestinal  tract.  Aside  from  the  salts,  other  soluble 
substances  of  the  secretory  juices  are  also  absorbed.  Thus 
the  urine  contains  traces  of  pepsin  and  also  urobilin, 
which  shows  that  the  biliary  i)roducts  must  have  been 
absorbed  and  eliminated  through  the  urine.  According 
'  Kubner :  Zeilschr.  f.  Biologic,  Bd.  15. 


28  DISEASES  OF  THE  INTESTINES. 

to  Schiff,'  the  bile  is  absorbed  from  the  small  intestine 
and  reaches  the  liver  with  the  blood  current  in  order  to  be 
eliminated  again  by  this  organ  from  the  blood. 

The  pancreatic  juice  being  the  principal  factor  in  the  di- 
gestion of  the  different  kinds  of  food,  it  appears  of  interest 
to  ascertain  how  much  of  these  foods  will  be  absorbed  after 
the  pancreas  has  been  excluded  from  participation  in  the 
act  of  digestion.  Minkowski  and  Abelmann  ^  experimented 
on  dogs  by  extirpating  the  pancreas,  and  found  that  forty- 
four  per  cent  of  the  proteids  and  from  fifty -seven  to  seventy- 
one  per  cent  of  carbohydrates  (amylaceous  food)  were  ab- 
sorbed, while  the  fats  remained  totally  unabsorbed.  The  fat 
contained  in  milk,  being  emulsified,  however,  was  absorbed 
to  the  extent  of  from  twenty-eight  to  fifty-three  per  cent. 

While  the  main  place  at  which  the  absorption  occurs  is 
the  small  intestine,  the  large  bowel  is  also  able  to  serve- in 
this  capacity.  Thus  aside  from  the  absorption  of  fluids 
and  salts  which  normally  takes  place  in  this  organ,  albu- 
minates and  carbohydrates  can  be  absorbed  in  consider- 
able amounts,  and  fats  in  small  quantities.  This  function 
of  the  large  bowel  is  of  great  practical  importance,  as  it  is 
utilized  in  some  conditions  for  nourishing  purposes  (rectal 
alimentation). 

3.  Motion. 

The  motor  function  or  peristalsis  of  the  intestine  has 
for  its  objects  the  thorough  mixture  of  the  contents  and 
their  propulsion  through  the  entire  canal  until  their  final 
exit  through  the  anus.      Nothnagel '  and  Braam-Houk- 

'  Schiflf :  Pflllger's  Arch.,  Bd.  3. 

*  Abelmann  :  "  Ueber  die  Ausnutzung  der  Nahrungsstoffe  nach  Pan- 
kreasexstirpation.  "    Inaug.  Dissert. ,  Dorpat,  1890. 

^  H.  Nothnagel :  "  BeitrSge  zur  Physiologie  und  Pathologie  des 
Darms, "  Berlin,  1884. 


PHYSIOLOGY.  29 

geest '  have  studied  the  process  of  intestinal  peristalsis  in 
animals.  After  laparotomy  the  latter  were  kept  in  a  bath 
of  physiological  salt-water  solution  of  38°  C,  and  the  mo- 
tions of  the  intestines  were  investigated. 

Three  types  of  intestinal  peristalsis  were  discerned:  1. 
The  ordinary  peristaltic  motion.  The  intestinal  tract  con- 
tracts at  a  certain  point  and  thereafter  relaxes.  The  con- 
traction is  carried  with  moderate  rapidity  for  a  certain 
length  contiguously  in  the  direction  toward  the  anus  and 
the  contents  are  pushed  forward.  2.  Oscillating  motions. 
An  intestinal  coil  is  here  moved  to  and  fro  all  along  its 
mesentery  without  any  particular  contraction  at  any  point. 
The  contents  are  not  propelled,  but  simply  mixed  up  dur- 
ing these  motions.  3.  Rotary  motions.  A  filled  intesti- 
nal coil  experiences  a  circular  constriction  which  is  rapidly 
carried  over  the  intestine  for  the  length  of  about  20  cm. 
This  is  exactly  the  same  process  as  described  under  1,  but 
executed  in  a  violent  manner. 

While  the  first  two  types  of  intestinal  peristalsis  are 
purely  physiological,  the  third  type  is  partly  pathological. 
It  is  met  with  only  when  the  contents  are  mixed  with  a 
great  deal  of  gas.  Thus,  after  indiscretions  in  diet,  we 
often  feel  this  kind  of  rapid  motion  going  along  with  a 
gurgling  sound  (tormina  intestinorum).  This  type  is  ob- 
served only  in  the  small  intestine,  but  never  in  the  large 
bowel. 

The  small  intestine  manifests  much  quicker  peristalsis 
than  the  large  bowel,  the  motions  of  which  are  very  slow. 
Here  the  haustra  during  the  act  of  peristalsis  contract  and 
then  protrude  in  regular  order.  The  small  intestine  while 
empty  does  not  show  any  motion  whatever,  but  after  the 
entrance  of  chyme  into  the  duodenum  intestinal  peristalsis 
'  Braam-Houkgeest :  PflUger's  Arch.,  Bd.  7.  p.  266. 


30  DISEASES  OF  THE  INTESTINES. 

begins.  It  is  not,  however,  transmitted  down  to  the  Bau- 
hinian  valve  without  interruption,  but  stops  as  a  rule  at  a 
certain  distance  from  its  starting-point  (about  20  cm.). 
After  an  intermission  of  some  duration  it  begins  again. 
Thus  one  or  more  intestinal  segments  may  be  in  a  state  of 
peristalsis  while  other  parts  of  the  intestine  in  between  are 
at  rest.  The  time  for  the  arrival  of  the  first  particles  of 
chyme  from  the  duodenum  into  the  caecum  is  about  two 
hours.  But,  of  course,  the  intestinal  peristalsis  must  con- 
tinue until  the  stomach  has  expelled  the  last  portions  of 
the  chyme,  that  is  to  say,  within  about  two  hours  after  the 
stomach  has  become  empty  the  small  intestine  as  a  rule 
will  also  be  found  free  of  contents.  The  forward  motion 
of  the  contents  in  the  large  bowel  is  a  very  slow  one  in- 
deed. It  takes  as  a  rule  from  twenty  to  twenty -four  hours 
for  the  fecal  matter  to  move  from  the  caecum  to  the  rec- 
tum. 

Antiperistalsis,  or  reversed  motion  of  the  large  bowel 
and  the  small  intestine,  beginning  at  the  anus  and  extend- 
ing upward,  has  never  been  seen  by  Nothnagel  in  physio- 
logical conditions. 

The  process  of  peristalsis  is  controlled  by  nervous  influ- 
ences. Auerbach's  and  Meissner's  plexus  most  i)robably 
contain  automatic  nerve  centres  for  this  act.  But  there 
are  also  other  centrally  located  nervous  agencies.  Thus 
after  great  mental  excitement  diarrhoea  very  often  results, 
showing  that  the  intestinal  peristalsis  must  have  been 
greatly  increased  through  the  influence  of  the  brain. 
Tliere  are  also  numerous  nerves  which  supervise  the  motor 
function  of  the  entire  intestinal  tract.  Pfliiger '  has  shown 
that  the  splanchnic  nerve  contains  inhibitory  fibres  for  the 

'  PfUger:  "Ueber  das  Hemmungs-  und  Nervensystem  fGr  die  peri- 
staltischen  Bewegungen  der  Gedftrme, "  Berlin.  1857. 


PHYSIOLOGY.  31 

intestinal  peristalsis.  According  to  Ehrmann,'  accelerat- 
ing and  inhibitory  fibres  supervising  intestinal  peristalsis 
are  contained  in  the  vagus  as  well  as  in  the  splachnicus, 
but  they  have  a  varied  function  according  to  the  way  they 
end,  whether  in  the  longitudinal  or  in  the  circular  muscles. 
The  longitudinal  muscles  are  stimulated  by  the  splanchnic 
and  paralyzed  by  the  vagus.  The  circular  muscles,  on  the 
other  hand,  are  stimulated  by  the  vagus  and  paralyzed  by 
the  splanchnic. 

Normally  the  chyme  acts  as  a  stimulus  on  the  intestinal 
canal  and  provokes  peristalsis  (through  the  influence  of  the 
nerves).  Too  cold  drinks,  indigestible  food,  organic  acids 
(present  in  too  large  amount)  may  often  cause  an  increased 
peristalsis  and  thus  produce  diarrhoea.  Toxic  substances 
which  are  ingested  or  developed  from  unwholesome  food 
may  have  the  same  effect. 

*  Ehrmann  :  Wiener  med.  Jahrbllcher,  1885. 


CHAPTER  II. 

METHODS  OF  EXAMINATION  AND  TREATMENT. 

EXAMINATION. 
Interrogation. 

The  examination  begins  with  a  thorough  interrogation 
of  the  patient.  Before  starting  with  the  narration  of  the 
present  ailment  a  general  outline  of  previous  sicknesses  is 
of  value.  Diseases  which  involve  the  intestinal  canal,  like 
typhoid  fever,  dysentery,  and  the  like,  are  of  special  impor- 
tance, as  they  are  liable  to  be  etiological  factors  in  the  de- 
velopment of  consecutive  ailments.  The  mode  of  living, 
with  regard  to  habits  (drinking,  smoking,  etc. ),  should  also 
be  inquired  into. 

The  patient  is  then  asked  to  describe  his  present  com- 
plaint. He  should  state  the  time  when  the  trouble  began 
and  its  nature.  If  the  chief  complaint  refers  to  pains,  it 
is  necessary  to  inquire  as  to  their  location  and  character. 
Pains  felt  in  the  neighborhood  of  the  navel  usually  origi- 
nate in  the  small  intestine ;  those  experienced  in  the  right 
iliac  region  often  emanate  from  the  appendix ;  while  those 
in  the  left  iliac  region  and  in  and  about  the  rectum  have 
their  starting-point  in  the  sigmoid  flexure  and  in  the  lower 
portion  of  the  rectum.  Are  the  pains  of  long  duration  or 
do  they  last  only  a  very  short  while,  a  few  seconds  or  min- 
utes? The  former  varietj^  is  usually  caused  either  by  an 
affection  of  the  sensory  nerves  of  the  intestines  or  by  some 
organic  lesion,  like  ulcers,  etc.    The  latter  variety,  to  which 


EXAMINATION.  33 

the  name  colic  is  applied,  is  due  to  a  strong  spasmodic 
contraction  of  a  certain  part  of  the  bowel.  Colicky  pains 
are  often  followed  and  relieved  by  the  passing  of  flatus  or 
of  fecal  matter.  Occasionally  these  pains  also  shift  from 
one  place  of  the  abdomen  to  another,  and  the  route  of  their 
travel  is  distinctly  felt  by  the  patient. 

Abnormal  sensations,  a  feeling  of  heat  or  cold  may  also 
be  experienced  over  a  certain  area  of  the  abdomen.  A  fre- 
quent or  constant  desire  for  an  evacuation  (tenesmus)  is 
encountered  in  dysentery  and  in  many  affections  of  the 
rectum.  It  is  also  advisable  to  inquire  whether  the  pains 
and  abnormal  sensations  appear  at  a  certain  period  of  the 
da}'  or  at  a  certain  time  after  meals  (soon  after  eating  or 
three  to  four  hours  later),  or  whether  they  are  experienced 
at  night  or  especially  in  the  early  morning  hours. 

The  condition  of  the  bowels  should  always  be  described 
in  detail.  Do  the  bowels  act  regularly  and  is  the  evacua- 
tion of  sufficient  quantity  ?  What  is  its  consistency  ?  Is 
the  stool  of  sausage-shape  and  pliable,  or  is  it  hard  or  very 
soft,  mush}^  watery?  What  is  its  color?  Is  it  dark  brown 
or  light  yellow  or  clay-colored  or  black?  Is  there  an  ad- 
mixture of  mucus  or  blood?  If  there  is  constipation,  in- 
quire whether  the  bowels  move  without  any  cathartics  after 
a  period  of  constipation  of  a  few  days,  and  if  not,  whether 
mild  aperients  are  sufficient  to  cause  an  evacuation,  or 
whether  a  strong  drastic  remedy  is  necessary.  Does  the 
constipation  alternate  with  periods  of  normal  movements 
or  with  periods  of  diarrhoea?  Are  the  periods  of  constipa- 
tion, if  cathartics  are  not  resorted  to,  accompanied  by  any 
marked  symptoms  (headaches,  dizziness,  anorexia,  etc.) 
or  not?  If  there  is  diarrhoea,  the  patient  should  state  how 
many  movements  a  day  he  has.     Is  he  disturbed  during 

the  night,  or  is  the  diarrhoea  confined  principally  to  the 
3 


34  DISEASES  OF  THE  INTESTINES. 

morning  hours?  Does  the  diarrhoea  alternate  with  periods 
of  constipation ;  does  it  disappear  after  a  change  of  climate, 
or  is  it  aggravated  by  mental  excitement?  Is  there  a  feel- 
ing of  exhaustion  in  connection  with  it?  Is  the  abdomen 
filled  up  with  gas  (meteorism)?  Does  this  phenomenon 
pertain  to  a  special  part  of  the  abdomen  (the  upper  or 
lower  region,  right  or  left  side),  or  does  it  extend  over  the 
entire  abdomen?  A  feeling  of  tension  in  the  abdomen 
with  frequent  passing  of  wind,  belching,  and  flatus,  is  com- 
monly designated  as  flatulency.  It  is  necessary  to  inquire 
whether  this  symptom  is  present  principally  at  a  certain 
time  of  the  day  or  continuously.  Absence  of  flatus  is  of 
significance  if  it  occurs  in  conjunction  with  obstinate  con- 
stipation, otherwise  it  is  of  no  consequence. 

In  all  intestinal  disorders  it  is  necessary  to  inquire  as 
to  the  state  of  the  stomach.  The  latter  organ  being  in 
direct  communication  with  the  intestines,  it  will  often  be 
subject  to  disturbances  in  intestinal  affections.  Com- 
plaints of  a  bad  taste  and  smell  in  the  mouth  are  often 
made,  principally  in  constipation.  Anorexia  and  nausea 
are  present  in  the  most  varied  intestinal  disorders.  Vom- 
iting frequently  occurs  in  intestinal  obstruction. 

Inspection. 

Inspection  of  the  abdomen  is  best  made  in  good  daylight 
with  the  patient  in  the  recumbent  posture,  but  should  also 
be  completed  by  inspection  in  the  standing  position.  The 
condition  of  the  skin  of  the  abdomen  is  first  examined. 
Sometimes  striae  or  scar-like  lines  running  parallel  to  each 
other  over  some  part  of  the  abdomen  (especially  the  lower 
part) ,  and  presenting  either  a  silvery  hue  or,  if  not  old,  a 
rather  reddish  tinge,  are  observed;  these  are  always  signs 
of  a  very  marked  former  distention  of  the  abdominal  pari- 


EXAMINATION.  35 

etes.  Thus  they  are  found  after  frequent  pregnancies,  also 
after  the  removal  of  rapidly  developing  abdominal  tumors, 
or  after  tapping  for  ascites.  These  striae  persist  long  after 
the  disappearance  of  the  conditions  which  caused  their 
development. 

Distention  of  the  abdominal  veins,  giving  them  a  bluish 
hue,  is  observed  whenever  the  return  flow  of  the  venous 
blood  of  the  lower  extremities  is  retarded  either  by  in- 
creased intra-abdominal  pressure  (ascites,  tumors  of  the 
abdomen)  or  by  thrombosis  or  compression  of  the  iliac 
vein  or  of  the  vena  cava  inferior.  Cirrhosis  of  the  liver 
and  compression  of  the  portal  vein  often  produce  the  same 
result.  In  the  latter  condition  there  is  an  extensive  forma- 
tion of  veins  over  the  navel  which  is  commonly  called  caput 
Medusae.  After  observing  the  appearance  of  the  skin,  the 
shape  of  the  abdomen  is  then  minutely  considered.  In 
normal  conditions,  in  grown  people,  the  abdomen  and  the 
chest  are  on  the  same  level  in  the  recumbent  position.  In 
small  children  the  abdomen  as  a  rule  is  somewhat  more 
prominent  than  the  thorax.  In  very  old  age  the  abdomen 
appears  somewhat  sunken.  The  greatest  degree  of  a  re- 
tracted or  trough-shaped  abdomen  is  found  in  stricture  of 
the  oesophagus  or  cardia,  in  basilar  meningitis,  and  in 
lead  poisoning.  Long-continued  inanition,  no  matter  of 
what  origin,  also  causes  this  phenomenon. 

Protrusion  of  the  abdomen  occurs  either  over  a  definite 
area  or  cfver  the  entire  surface.  The  abdomen  may  pre- 
sent the  shape  of  a  round  hemisphere  or  of  a  flattened  one 
if  there  is  an  accumulation  of  air  and  gas  in  the  intestines 
(intestinal  meteorism).  This  occurs  principally  in  atonic 
conditions  of  the  intestines  and  in  hysteria.  A  uniform 
protrusion  of  the  abdomen  or  a  general  bloated  condition 
is  present  in  general  peritonitis,  occasionally  also  in  pro- 


36  DISEASES  OF  THE  INTESTINES. 

nounced  atony  of  the  intestines.  In  case  of  ascites,  no 
matter  to  what  cause  it  is  due  (tumors,  cirrhosis  of  the 
liver,  nephritis,  etc.),  the  abdomen  is  also  more  or  less 
evenly  protuberant  above,  while  the  lower  parts  bulge  out 
somewhat  in  the  recumbent  position.  This  is  caused  by 
the  accumulation  of  fluid  in  the  lower  portions  of  the  ab- 
dominal cavity.  Change  of  posture  alters  the  shape  of  the 
abdomen.  This  applies  to  the  early  period  of  ascites, 
during  which  the  abdominal  cavity  is  not  yet  filled  to  its 
maximum ;  later,  when  this  is  the  case,  the  abdomen  ap- 
pears uniformly  enlarged,  and  there  is  no  bulging  out  of 
any  particular  portion.  Change  of  position  then  no  longer 
alters  its  shape. 

Protrusion  of  a  certain  part  of  the  abdomen  is  noticed 
in  many  cases  of  neoplasm,  sometimes  in  fecal  concretions, 
and  occasionally  in  appendicular  abscesses.  In  umbilical 
hernia  a  small,  more  or  less  roundish  protrusion  is  noticed 
in  the  region  of  the  navel.  In  diastasis  of  the  rectus  ab- 
dominis muscles  there  appears  in  the  middle  line  of  the 
abdomen  a  long  protrusion  of  sausage  shape  consisting  of 
prolapsed  intestine.  Sometimes  there  is  a  pronounced 
protrusion  of  this  area  owing  to  the  escape  of  a  large  mass 
of  the  bowel  through  the  gap  in  the  muscles. 

In  patients  with  thin  abdominal  walls  very  small  sau- 
sage-shaped prominences  are  occasionally  visible  which 
quickly  change  their  configuration,  appearing  now  in  one 
place  and  now  in  another.  This  phenomenon  is  caused  by 
peristaltic  contractions  of  the  small  intestine.  As  a  rule, 
they  are  not  associated  with  pain  and  do  not  denote  a  mor- 
bid condition.  Sometimes  similar  peristaltic  waves  in  the 
small  intestine  appear  periodically  and  annoy  the  patient. 
Here  they  may  be  caused  by  nervous  influences.  Peri- 
staltic contractions  of  the  small  intestine  appearing  in  a 


EXAMINATION. 


37 


violent  manner  and  caused  by  a  stenosis  or  an  obstniction 
of  the  intestinal  lumen  are  usually'  much  more  pronounced, 
that  is,  the  prominences  are  much  higher  and  involve 
larger  areas  of  intestine,  the  waves  moving  with  greater 
rapidity  and  strength  and  being  accompanied  by  intense 
pain.     Visible  peristaltic  contractions  of  the  large  bowel 


Fig.  10.— Sims'  Rectal  Speculum. 


Fig.  11.— Allingham's  Rectal  Speculum. 


are  ordinarily  met  with  only  in  cases  of  i^artial  or  total 
intestinal  obstruction. 

Inspection  of  the  anal  region  is  best  made  when  the  pa- 
tient lies  on  his  side  with  his  back  toward  the  examiner. 
The  buttocks  are  held  apart  with  the  hands,  and  thus  thor- 
ough inspection  of  the  anus  is  rendered  possible.  Piles, 
fissures,  fistulae  may  thus  be  discovered. 

Proctoscopy. — In  order  to  inspect  the  anus  internally  and 
also  the  rectum  it  is  necessary  to  introduce  a  speculum. 
This  method  of  inspecting  the  rectum  is  called  proctoscopy. 
Of  the  many  specula  devised  for  this  purpose  I  would 
mention  those  of  Sims,  Allingham,  and  Kelly  as  the  most 
practical  (see  Figs.  10,  11,  12).     Kelly's  speculum,  which 


38  DISEASES   OP  THE  INTESTINES. 

consists  of  a  hollow  metallic  tube  provided  with  an  obtu- 
rator, is  best  suited  for  this  purpose.  Before  inserting  the 
instrument  it  must  be  thoroughly  smeared  with  sweet  oil 
or  vaseline.  In  cases  in  which  the  rectal  region  is  inflamed 
or  ulcerated,  it  is  necessary,  in  order  to  avoid  too  much 
pain,  to  induce  anaesthesia  of  these  parts  by  painting  them 
with  a  ten-per-cent  cocaine  soliition  or  by  the  introduction 


Fio.  12.— Kelly's  Rectal  Speculum. 

of  a  suppository  of  opium  with  belladonna  or  of  cocaine. 
It  is  hardly  necessary  to  say  that  endoscopy  of  the  rectum 
must  not  be  performed  until  after  a  thorough  evacuation  of 
the  bowels.  It  is  best  to  wash  out  the  gut  before  examin- 
ing with  the  speculum.  When  the  speculum  is  in  j^osition 
a  portion  of  the  rectal  mucosa  becomes  visible  when  good 
light  is  thrown  into  the  endoscopic  tube.  The  source  of 
light  is  immaterial,  although  it  is  best  to  have  electric 
light.  Usually  a  small  electric  lamp  with  a  reflecting  mir- 
ror fastened  to  the  head  of  the  examiner  best  serves  the 
purpose.  The  higher  up  the  bowel  has  to  be  examined  the 
longer  the  speculum  must  be.  After  the  full  insertion  of 
the  instrument  the  highest  portion  of  the  bowel  is  first 


EXAMINATION.  39 

examined,  and  while  gradually  drawing  out  the  speculum 
the  entire  area  of  the  bowel  through  which  it  passes  will 
be  brought  into  view.  Small  ulcers,  atrophic  and  congested 
conditions  can  thus  be  easily  recognized  and  malignant 
growths  detected  at  an  early  period. 

Transillumination. — Transillumination  of  the  bowel  was 
first  suggested  by  myself '  and  later  practised  principally 
by  Heryng  and  Reichmann."  After  a  thorough  cleansing 
of  the  bowel  by  means  of  high  irrigation  about  one  quart 
of  water  is  injected  and  an  electric  illuminator  (very  similar 
in  construction  to  the  gastrodiaphane)  is  inserted  into  the 
rectum.  The  examination  must  be  made  in  a  dark  room. 
By  gradually  pushing  up  the  instrument  successive  portions 
of  the  bowel  may  be  transilluminated.  This  method,  how- 
ever, has  not  as  yet  proven  to  be  of  any  practical  value. 

Roentgen  Bays. — The  examination  of  the  colon  by  means 
of  Roentgen  rays  seems  to  be  somewhat  more  promising. 
A  soft-rubber  rectal  tube  through  which  a  flexible  wire 
passes  is  introduced  into  the  bowel  as  high  up  as  possible 
and  the  patient  exposed  to  the  Roentgen  apparatus.  The 
wire  within  the  tube  becomes  visible  as  a  shadow,  and  thus 
marks  the  course  of  the  bowel  in  which  it  lies.  Inasmuch 
as  it  is  hardly  possible  to  insert  an  instrument  higher  up 
than  the  sigmoid  flexure,  the  following  i)rocedure  for  the 
Roentgen  examination  appears  to  be  of  greater  value :  The 
bowel  is  filled  with  two  quarts  of  water  in  which  60  gm.  (2 
ounces)  of  subnitrate  of  bismuth  are  suspended  by  means 
of  a  starch  solution.  This  mixture  penetrates  almost  the 
entire  colon,  and  thus  the  position  of  the  large  bowel  can 
be  determined  by  the  Roentgen  rays. 

'  Max  Einliorn  .  "  Die  Gastrodiapbanie.  "    New-Yorker  medicinlsche 
Monatsschrift,  November,  1889. 
^  Heryng  und  Reichmann  .  Therapeutische  Monatshefte,  1892. 


40  DISEASES  OP  THE   INTESTINES. 

Palpation. 

Palpation  is  the  most  important  procedure  available 
among  the  methods  of  examination  in  abdominal  diseases. 
It  is  best  performed  in  the  recumbent  position  of  the 
patient,  the  head  being  slightly  raised  and  the  abdominal 
muscles  relaxed  as  much  as  possible.  In  order  to  effect 
this  the  room  must  be  of  a  comfortable  temperature  and 
the  hands  of  the  examiner  warm.  If  the  patient  is  fidgety 
and  contr&cts  his  abdominal  walls,  it  is  necessary  to  talk 
to  him  and  to  draw  his  attention  away  from  the  exam- 
ination. I  have  often  noticed  a  great  relaxation  of  the 
muscles  during  an  expiration  following  a  deep  inspira- 
tion. Whenever,  therefore,  it  is  difficult  to  obtain  relaxa- 
tion of  the  abdomen  I  tell  the  patient  to  take  a  deep 
inspiration  and  then  make  use  of  the  following  period  of 
expiration  for  palpation.  If  all  these  means  fail  to  relax 
the  abdominal  muscles,  palpation  may  be  tried  in  a  warm 
tub  bath,  as  first  recommended  by  Chlapowski,  or  under 
chloroform  narcosis.  In  cases  of  great  diagnostic  impor- 
tance the  latter  method  is  certainly  j^referable.  In  palpat- 
ing the  abdomen  it  is  advisable  first  to  examine  with  the 
entire  palm  of  the  hand,  applying  very  little  pressure,  thus 
determining  the  state  and  consistency  of  the  abdomen. 
The  hand  may  thus  be  passed  over  the  entire  abdominal 
surface  from  one  place  to  another.  This  having  been  done, 
palpation  is  then  performed  with  a  trifle  more  pressure,  the 
finger  tips  being  used  for  this  purpose.  The  latter  procedure 
serves  for  exploring  a  more  circumscribed  area.  Finally, 
deep  palpation  is  practised  for  which  considerable  pressure 
may  be  required. 

Palpation  aids  us  in  discovering  the  position  of  some  of 
the  abdominal  organs.     With  regard  to  the  intestine  the 


EXAMINATION.  41 

following  portions  are  often  accessible  to  this  method  of  ex- 
amination :  the  caecum  and  part  of  the  ascending  colon,  the 
transverse  colon,  and  the  sigmoid  flexure.  In  some  in- 
stances the  descending  colon  above  the  sigmoid  flexure  can 
also  be  palpated,  especially  if  it  is  filled  with  hard  scybala. 
The  jejunum  and  ileum  filling  most  of  the  lower  part  of  the 
abdominal  cavity  (from  the  navel  downward)  cannot  nor- 
mally be  separately  outlined. 

For  the  detection  of  tumors  in  the  abdomen  palpation  is 
of  great  service.  By  means  of  it  we  gain  information  with 
regard  to  their  size,  shape,  and  consistency.  An  uneven 
protuberant  surface  is  characteristic  of  malignant  growths, 
while  an  even  surface  is  more  often  found  in  benign  neo- 
plasms or  in  intussusception.  A  fecal  tumor  can  be  recog- 
nized by  indentations  made  by  pressure  with  the  fingers. 
Sometimes  after  such  pressure  it  is  possible  to  notice  for  a 
moment,  when  raising  the  finger,  a  slipping  off  of  the  in- 
testinal wall  from  the  fecal  mass.  This  phenomenon,  first 
described  by  Gersuny  '  under  the  name  of  "  Klebesymptom, " 
I  have  observed  quite  frequently  and  consider  of  practical 
value.  , 

Another  important  object  of  palpation  is  to  ascertain 
whether  there  is  tenderness  or  pain  on  pressure.  While 
strong  pressure  exerted  upon  the  intestine  through  the  ab- 
dominal wall  eve'n  normally  elicits  an  unpleasant  sensation, 
there  is,  however,  no  distinct  pain  connected  with  this  act. 
Tenderness  on  slight  pressure  is  often  present  in  inflam- 
matory conditions  of  the  bowels  and  also  in  ulcerative 
processes.  A  circumscribed  pain  on  pressure  is  present 
in  the  api)endicular  region  (McBurney's  point)  in  appen- 
dicitis, especially  in^the  acute  form.  In  chronic  appendi- 
citis the  pain  may  be  elicited  only  upon  very  strong  press- 
'  Gersuny  :  Wiener  klinische  Wochenschrift,  1896,  No.  40. 


42 


DISEASES  OF  THE  INTESTINES. 


FULL  ;  i^t 

^OHN  RBY.VDERS-CO.     WBW  TORE. 

Fig.  13.— Finger  Cot. 


ure.  In  ulcerations  of  the  bowel  there  may  be  also  one 
or  several  circumscribed  areas  very  painful  to  pressure. 
In  pains  due  to  a  purely  nervous  aflfection  of  the  bowel 

pressure  may  aflford 


relief.  If  a  mere 
touching  of  the  ab- 
domen elicits  pain, 
it  is  a  sign  either  of 
an  extensive  inflam- 
matory process  with- 
in the  bowel  or  of 
peritonitis. 

Palpation  in  the 
form  of  tapping  oc- 
casionally produces  a  splashing  sound  (clapotage)  over 
some  portions  of  the  bowel.  The  splashing  sound  can  be 
elicited  over  the  colon  only  when  it  is  filled  with  liquid  or 
semi-liquid  matter  and  gas.  It  can  be  discovered  off  and 
on  either  in  the  caecum  and  in  the  portion  of  the  bowel  im- 
mediately above  it  or  in  the  sigmoid  flexure.  In  the  small 
intestine  clapotage  can  be  obtained  only  in  the  dilated 
portion  of  the  gut  above  a  stricture.  Boas  '  first  suggested 
the  method  of  filling  up  the  bowel  with  from  500  to  600 
c.c.  of  water  and  then  examining  for  the  splashing  sound 
along  the  colon.  When  the  patient  has  been  thus  pre- 
pared, clapotage  can  be  produced  in  the  sigmoid  flex- 
ure ;  and  by  having  the  patient  turn  on  his  right  side,  it 
can  occasionally  be  produced  in  the  transverse  colon,  and 
finally  in  the  csecal  region.  In  cases  of  atony  of  the  bowel 
Boas  was  able  to  evoke  the  splashing  sound  even  after 
the  injection  of  only  200  to  300  c.c.  of  water.     Frieden- 

'  Boas  : ' "  Diagnostik  und  Therapie  der  Magenkrankheiten,  "  Theil  i, , 
1897,  4te  Auflage.  p.  105. 


EXAMINATION. 


43 


wald '  has  also  practised  the  same  method  with  advan- 
tage. Whenever  the  splashing  sound  can  be  produced  in 
the  colon  it  serves  the  purpose  of  determining  the  situa- 
tion of  this  organ. 

The  rectum  is  best  palpated  with  the  index  finger  well 
oiled  or  smeared  with  vaseline  or  encased  in  a  rubber  cot 
(Fig.  13)  and  anointed  in  the  same 
way.  The  condition  of  the  anus  and 
the  lower  portion  of  the  rectum  can 
be  advantageously  investigated  with 
the  finger.  The  examination  may  be 
made  either  in  the  recumbent  posture 
of  the  patient,  in  the  side  or  knee- 
elbow  position,  or  in  the  standing  po- 
sition. In  the  latter  instance  it  is 
well  to  have  the  patient  exert  down- 
ward pressure  upon  the  rectum. 
Hemorrhoids,  polypi,  and  malignant 
growths  can  thus  be  occasionally  dis- 
covered. In  cases  in  which  there  is 
a  suspicion  of  malignant  growths  in- 
volving i)ortions  of  the  colon  not  ac- 
cessible either  to  i)alpation  by  the 
finger  or  inspection  with  the  procto- 
scope, examination  with  the  entire 
hand  in  chloroform  narcosis  can  be 
tried  as  first  practised  by  Simon." 
After  dilating  the  anal  sphincters,  the 
entire  right  hand  and  the  arm  are  inserted  into  the  bowel 
through   the  anus,  and  thus  the  higher  portions  of  the 


Fig.  14a.   Fig.  15.   Fig.  14b. 

Figs.  14a  and  14b.— Cylin- 
drical Bougies. 

Fig.  15.— Olive-Point  Bou- 
gie. 


'  J.  Friedenwald  :  Medical  News,  1894. 

"^  Simon    Verbandlungeu  der  deutscben  Gesellsch.  f.  Chirurgie,  1871. 
and  Deutsche  Klinik    1*^72 


44  DISEASES  OF  THE  INTESTINES. 

colon  palpated  with  the  fingers.  This  method  can  be  rec-r 
ommended  only  in  cases  of  extreme  importance,  as  such 
an  examination  is  liable  to  produce  unpleasant  symptoms, 
as,  for  instance,  incontinence  of  the  rectum,  tearing  of  the 
mucous  membrane,  etc. 

Palpation  of  the  rectum  by  means  of  sounds  is  performed 
whenever  there  is  suspicion  of  a  stricture  involving  por- 
tions of  the  bowel  not  accessible  to  examination  by  the  fin- 
ger. For  this  purpose  either  bougies  (see  Figs.  14  and 
15),  or,  still  better,  rectal  tubes  of  various  calibre  may  be 
employed.  Kuhn '  has  recently  recommended  the  use  of 
tubes  provided  with  a  metal  spiral.  He  believes  that 
these  penetrate  the  colon  farther  up  without  bending. 
His  statements  have,  however,  not  as  yet  been  corroborated. 

Percussion. 

Percussion  is  of  less  importance  than  palpation.  In 
many  instances  it  serves  to  confirm  the  results  obtained 
b}^  the  latter.  In  percussing  the  intestines  it  is  best  to 
use  the  fingers.  It  should  be  done  rather  gently.  Mild 
percussion  permits  the  discernment  of  slight  difi'erences 
of  sound  much  better  than  strong  percussion.  As  is  well 
known,  i)ercussion  over  empty  intestinal  coils  or  those 
filled  with  gas  or  air  gives  a  tympanitic  sound  which  is 
louder  over  the  large  than  over  the  small  bowel.  Intestinal 
coils  filled  with  liquid  or  solid  substances  give  dulness. 
In  raeteorism  of'the  intestines  percussion  will  elicit  a  tym- 
panitic sound  of  a  deeper  pitch  than  normally,  and  there 
will  be  besides  some  areas  of  dulness  over  the  abdomen. 
The  region  of  the  liver  and  spleen  will  here  show  normal 
conditions  with  regard  to  the  percussion  sounds.  Meteor- 
ism  of  the  abdomen  as  a  result  of  perforation  will  manifest 
•  Eubn  :  Deutsche  raed.  Wochenschr.,  1897.  Nos.  36  and  37. 


EXAMINATION.  45 

an  evenly  diffused  tympanitic  sound  all  over  the  abdomi- 
nal cavity.  Usually  the  dulness  over  the  region  of  the 
liver  and  spleen  will  have  disappeared.  In  ascites  percus- 
sion will  reveal  an  area  of  dulness  in  the  lower  parts  of  the 
abdomen,  and  there  will  be  a  change  in  the  character  of 
the  sound  on  altering  the  position  of  the  patient.  Tumors 
of  the  intestine  give  dulness  on  percussion.  Fecal  accu- 
mulations and  appendicular  abscesses  will  also  manifest 
dulness  on  percussion. 

Auscultation. 

Auscultation  is  not  of  great  significance  in  diseases 
of  the  intestine.  Palpation  of  intestinal  coils  with  the 
application  of  moderate  pressure  may  elicit  either  a  gur- 
gling noise  or  a  friction  sound.  The  latter  was  formerly 
believed  to  be  pathognomonic  of  typhoid  fever.  Of  late, 
however,  it  has  been  recognized  that  this  sign  is  found  in 
many  other  conditions.  At  the  time  of  active  peristalsis 
all  kinds  of  gurgling  sounds  are  heard  within  the  intestine 
(borborygmi),  which,  however,  are  not  of  much  impor- 
tance. In  chronic  stenosis  of  the  intestine  very  loud  noises 
are  at  times  heard,  caused  by  the  sudden  passage  of  liquid 
and  gaseous  contents  through  the  stricture  under  great 
pressure.  In  the  latter  affection  splashing  sounds  can  also 
be  easily  produced  over  the  enlarged  bowel  above  the  stric- 
ture. Often  a  tympanitic  sound  of  a  metallic  character  can 
be  heard. 

Ivfiation  of  the  Intestine  with  Carbonic  Acid  Gas  or  Air. 

Inflation  of  the  intestine  is  one  of  the  most  important 
diagnostic  procedures.  Von  Ziemssen,'  who  first  intro- 
duced this  method  of  examination,  injected  successively 

'  Von  Ziemssen :  Deutsches  Archiv  f.  klinische  Medicin,  1883,  Bd. 
33,  S.  235. 


46  DISEASES  OF  THE  INTESTINES. 

into  the  bowel  two  solutions,  one  containing  tartaric  acid, 
the  other  bicarbonate  of  sodium  in  water.  The  carbonic 
acid  gas  developing  fills  the  large  bowel,  which  can  then 
be  recognized  by  the  tympanitic  percussion  sound,  or,  in 
rare  instances,  by  inspection.  Schnetter,'  of  New  York, 
suggested  filling  the  bowel  with  carbonic  acid  gas  by  means 
of  a  tube  attached  to  an  inverted  siphon  containing  soda- 
water,  the  valve  of  which  is  i^ressed.  Here  the  carbonic 
acid  gas  runs  into  the  bowel  without  any  admixture  of 
water.  Rosenbach ''  made  use  of  liquefied  carbon  dioxide 
from  a  sparklet.  Instead  of  the  latter  Runeberg '  recom- 
mended inflation  of  the  intestines  by  means  of  air.  This 
is  best  done  by  a  rectal  tube  to  which  a  compressible  air 
suction  bulb  is  attached.  The  advantage  this  method  offers 
consists  in  the  possibility  of  regulating  the  amount  of  the 
introduced  air.  In  order  to  be  able  to  measure  the  amount 
of  insufflated  air,  Damsch  *  has  recommended  the  employ- 
ment of  a  syringe  of  known  capacity.  An  ordinary  bicycle 
pump  can  be  used  for  this  purpose,  the  rectal  tube  being 
attached  to  it. 

Inflation  of  the  bowel  is  of  importance  in  detecting 
a  stenosis  of  this  organ.  Under  ordinary  conditions  the 
injected  air  evenly  distends  the  entire  colon,  as  can  be 
proven  by  inspection  and  percussion.  In  case  there  is  a 
stenosis  in  the  large  intestine  the  air  will  distend  prin- 
cipally that  portion  of  the  bowel  below  the  stricture,  while 
that  above  will  remain  unchanged.  It  is  thus  possible  to 
recognize  the  seat  of  a  constriction.  The  significance  of  this 
diagnostic  means,  however,  is  confined  merely  to  strictures 

'  Schnetter :  Deutsches  Archiv  f .  klinische  Medicin,  1884,  Bd.  34 
S.  638. 
*0.  Rosenbach:  Berliner  klinische  Wochenschrift,  1889,  No.  28. 
*  Runeberg:  Deutsches  Archiv  f.  klinische  Medicin.  Bd.  34,  S.  460. 
♦Damsch:  Berliner  klinische  Wochenschrift,  1889,  No.  75. 


EXAMINATION.  47 

of  a  high  degree,  while  a  beginning  stenosis  of  the  bowel 
cannot  be  thus  recognized,  as  the  air  will  pass  through  it. 

The  position  of  the  colon  can  be  ascertained  by  this  pro- 
cedure. Normally  the  transverse  colon  is  situated  some- 
what above  the  navel,  while  in  cases  of  enteroptosis  it  may 
be  found  about  a  hand's  width  above  the  symphysis. 

Inflation  of  the  colon  is  also  of  importance  in  the 
differential  diagnosis  of  abdominal  tumors.  As  is  well 
known,  tumors  of  the  intestine  will  become  more  distinct 
after  inflation  of  the  bowel  with  air,  while  tumors  of  the 
kidney,  of  retroperitoneal  glands,  and  of  the  spine  tend  to 
recede.  According  to  Minkowski, '  abdominal  tumors  after 
filling  the  colon  with  air  or  water  are  usually  slightly 
shifted  in  the  direction  of  the  organ  to  which  they  be- 
long. 

Inflation  of  the  bowel  with  air  impregnated  with  ether 
has  been  suggested  by  Dr.  Sutton  ^  as  a  means  of  recog- 
nizing intestinal  perforation.  For  this  purpose  he  makes 
use  of  a  bottle  filled  with  two  drachms  of  ether.  The  bot- 
tle is  provided  with  a  perforated  rubber  cork  to  which  are 
attached  two  rubber  tubes  provided  with  stopcocks.  One 
of  these  is  then  attached  to  a  bicycle  pump  and  the  other 
to  an  ordinary  rectal  tube.  The  air  pumped  into  the  bowel 
must  pass  through  the  bottle  containing  ether  and  thus 
takes  up  the  ether  vapors.  In  case  of  perforation  of  the 
bowel,  the  ether  quickly  escapes  through  the  opening  into 
the  abdominal  cavity  and  equally  distends  it;  while,  if 
there  is  no  perforation,  the  bowel,  first  the  large  and  later 
the  small  intestine,  becomes  filled  with  air  and  ether;  ulti- 
mately the  ether  reaches  the  stomach  and  is  usually  eruc- 

'  Minkowski:  Berliner  klinische  Wochenschrift,  1888,  No.  31. 

*E.  M.  Sutton:  "Diagnosis  of  Intestinal  Perforations  by  Means  of 
Ether  Inflation  per  Rectum. "  Journal  of  the  Am.  Med.  Assn. ,  Decem- 
ber 30th,  1899. 


48  DISEASES  OP  THE  INTESTINES. 

tated.  The  ether  can  then  be  recognized  by  its  charac- 
teristic odor.  It  seems  that  this  procedure  is  especially 
useful  in  gunshot  wounds  of  the  abdomen. 

Injection  of  Water  per  Anum. 

This  is  done  by  means  of  a  rectal  tube  and  a  fountain 
syringe  provided  with  a  scale  indicating  the  amount  of 
water  used.  In  case  of  stricture,  especially  of  the  lower 
portion  of  the  colon,  the  quantity  of  water  which  can  be 
injected  is  not  great,  while  ordinarily  from  three  to  five 
quarts  of  water  can  be  poured  in.  Inasmuch  as  even  nor- 
mally some  people  are  not  able  to  hold  large  amounts  of 
water  in  the  bowels  without  experiencing  considerable  dis- 
comfort, the  quantity  of  fluid  which  can  be  injected  with- 
out pain  is  not  of  great  diagnostic  value.  Filling  up  the 
bowel  with  water  can  also  be  made  use  of  for  the  determi- 
nation of  the  position  of  the  colon,  as  this  organ  will  then 
give  a  dull  sound.  For  this  purpose,  however,  the  proced- 
ure in  question  is  not  so  good  as  the  above-described  method 
of  inflation  with  air. 

Lavage  of  the  Bowel. 

Lavage  of  the  bowel  in  a  similar  manner  as  performed 
in  the  stomach  has  been  recommended  by  Boas '  for  di- 
agnostic purposes.  It  is  best  performed  in  the  lateral 
posture  of  the  patient  after  an  evacuation  of  the  bowels. 
The  same  apparatus  as  for  gastric  lavage  may  be  used 
here.  The  rectal  tube,  which  represents  the  stomach  tube 
employed  in  gastric  lavage,  is  attacjied  to  a  long  piece 
of  rubber  tubing  provided  with  a  big  funnel.  The  rectal 
tube  is  inserted  as  high  up  in  the  bowel  as  possible  and 
then  the  water  is  poured  in  until  the  patient  begins  to 
'  J.  Boas :  Deutsche  Aerzte-Zeitung,  1895.  Nos.  2  and  3. 


EXAMINATION.  49 

feel  some  discomfort.  As  soon  as  this  is  the  case  the  fun- 
nel is  lowered  and  thus  the  water  returns.  The  latter  is 
now  subjected  to  a  thorough  examination.  Normally  the 
returning  water  appears  pretty  clear  or  slightly  turbid  by 
the  admixture  of  small  particles  of  mucus,  epithelial  cells, 
and  fecal  matter.  In  catarrh  of  the  large  bowel  a  consid- 
erable quantity  of  mucus  is  found.  Ulcerative  processes 
accompanied  by  hemorrhages  or  by  suppuration  are  often 
recognized  by  the  admixture  of  either  pus  or  blood  in  the 
wash-water.  Occasionally  exfoliated  pieces  of  intestinal 
mucosa  are  found  in  the  wash-water,  and  a  microscopical 
examination  of  them  may  be  of  diagnostic  importance. 

Examination  of  ihe  Fceces. 

The  examination  of  the  faeces  is  of  much  service  in  dis- 
eases of  the  intestine.  The  faeces  represent  the  end  pro- 
duct of  the  digestive  act,  consisting  of  residue  unsuitable 
for  further  assimilation.  It  is  evident  that  a  thorough 
knowledge  of  the  dejecta  will  throw  light  upon  the  nature 
of  the  activity  of  the  intestines. 

The  normal  faeces  consist  of  changed  and  unchanged 
remnants  of  food,  bacteria,  traces  of  digestive  juices,  epi- 
thelial cells,  and  salts.  The  quantity  of  the  faeces  for 
twenty-four  hours  varies  greatly  with  the  kind  of  food 
taken.  In  a  mixed  diet  it  usually  amounts  to  from  four  to 
seven  ounces.  The  color  of  the  faeces  is  usually  dark  brown 
owing  to  changed  bile  pigment,  the  bilirubin  having  be- 
come changed  in  the  intestine  into  urobilin.  The  diet  has 
great  influence  upon  the  color  of  the  faeces.  Meat  pro- 
duces a  dark  brown,  milk  a  light  yellow  color,  cacao  a 
more  or  less  brownish-red,  huckleberries  and  claret  a  dirty 
black-brown  color  with  a  greenish  liue.  The  salts  of  iron 
and  manganese  give  rise  to  a  darker  color  than  the  usual 


60  DISEASES  OF  THE  INTESTINES. 

one,  while  bismuth  produces  a  more  or  less  blackish  color. 
According  to  Quincke,'  all  these  metals  are  reduced  to 
oxydule  combinations  which  are  responsible  for  these 
colors,  while  the  former  belief  that  these  metals  formed 
sulphides  is  not  correct.  Calomel  frequently  produces  a 
greenish  hue,  while  senna,  santonin,  gamboge,  and  rhubarb 
give  rise  to  an  intensely  yellow  color. 

The  fsBces  are  normally  somewhat  soft  in  consistency  and 
have  a  sausage  shape.  In  abnormal  conditions  the  con- 
sistency may  be  changed  in  two  directions.  The  dejecta 
may  be  greatly  hardened  and  aj^pear  in  small  balls,  or  in 
the  form  of  very  thin  cylinders.  On  the  other  hand,  the 
stools  maj'  be  abnormally  mushy  or  even  liquid.  The 
hardened  stools  which  occa8ionall3'  show  grooved  impres- 
sions from  the  taenia  coli  bear  testimony  to  their  long 
sojourn  in  the  intestine,  thus  being  exsiccated  from  the 
complete  absori)tion  of  water.  They  are,  however,  by  no 
means  characteristic  of  a  stenosis  of  the  intestine.  Very 
soft  dejecta  may  be  either  waterj',  as  for  instance  in 
cholera  nostras  or  asiatica,  or  they  are  mixed  with  mucus 
which  can  be  easily  seen  when  pouring  the  dejecta  into  a 
glass  and  inverting  it,  when  the  mucus  as  a  rule  adheres  to 
the  surface  of  the  vessel. 

Odor.  —The  characteristic  odor  of  the  faeces  is  normally 
caused  by  skatol  and  also  to  a  less  degree  b}-  indol.  The 
fecal  odor  ma}'  be  increased  whenever  the  faeces  have  been 
retained  much  longer  than  normally  in  the  intestine.  On 
the  other  hand,  faeces  occasionally  present  very  little  or  no 
odor  when  their  sojourn  in  the  intestine  has  been  very 
short.  As  a  good  instance  of  the  latter  variety  the  so- 
called  rice-water  movements  in  cholera  nostras  and  cholera 
asiatica  may  be  mentioned.     Movements  with  a  fetid  odor 

'  Quincke  :  MQochner  mediziniscbe  Wochenschrift,  1896,  No.  36. 


EXAMINATION  51 

occur  jiriDcipally  in  maliguant  growths  of  the  large  bowel 
accompauied  bj'  ulcerative  processes. 

Remnants  of  Food  in  the  Fceces. — Undigested  remnants  of 
food,  macroscopically  visible,  occur  in  the  faeces.  Nor- 
mally, however,  only  small  particles  of  vegetable  sub- 
stances, like  potatoes,  asparagus,  spinach,  peas,  etc.,  are 
found,  while  remnants  of  meat  can  never  be  discovered  with 
the  naked  eye.  In  case  particles  of  meat  are  visible,  it  in- 
dicates a  severe  lesion  of  the  intestinal  tract.  If  large 
amounts  of  undigested  food  (even  vegetable  matter)  are 
present  in  the  faeces,  it  is  also  an  indication  of  an  existing 
severe  lesion. 

Abnormal  admixtures  frequently  occur  in  the  faeces,  and 
are  occasionally  of  great  diagnostic  importance.  Thus, 
blood  may  be  found  either  in  its  fresh  condition  (red)  or  it 
may  be  very  dark  but  not  coagulated.  In  both  instances 
the  blood  comes  from  the  lower  portions  of  the  large  bowel. 
Sometimes  the  blood  appears  in  a  more  changed  and  de- 
composed form,  giving  the  faeces  the  appearance  of  tar.  In 
this  instance  it  priginates  from  the  higher  portions  of  the 
bowels  or  from  the  stomach. 

An  admixture  of  pus  in  the  dejecta  which  can  be  macro- 
scopically recognized  occurs  only  in  instances  in  which  pus 
exists  in  the  lower  portions  of  the  large  intestine.  For  if 
there  is  pus  present  in  the  higher  portions  of  the  bowel,  it 
is  usually  changed  before  its  exit  in  such  a  manner  that 
it  cannot  be  detected  unless  the  amount  is  very  consider- 
able. 

Fragments  of  tumor  (polypi  or  torn  off  particles  of  can- 
cer) are  occasionally  found  in  the  dejecta.  A  thorough 
examination  of  these  may  be  of  great  help  in  the  diagnosis. 

3fucus,  although  a  normal  constituent  of  the  faeces,  can- 
not be   discovered  in  large  amounts  uuder  physiological 


62  DISEASES  OP  THE  INTESTINES. 

conditioiis.  Macroscopically  visible  mucus  may  exist  in 
the  following  forms :  (1)  It  may  surround  the  fecal  matter 
in  the  form  of  a  glassy  layer.  This  usually  indicates  a 
diseased  condition  of  the  lower  portion  of  the  bowel.  (2) 
The  mucus  may  appear  in  the  form  of  membranes  and  may 
be  evacuated  either  alone  or  after  a  fecal  evacuation.  This 
often  occurs  in  membranous  enteritis.  (3)  The  mucus  may 
appear  in  a  mushy  movement  having  a  yellowish  coloration 
and  be  well  mixed  with  fseces.  If  a  glass  rod  is  dipped 
into  such  an  evacuation  the  mucus  adheres  to  it.  (4)  The 
mucus  exists  in  small  particles  visible  with  the  naked  eye 
and  floating  in  the  watery  dejecta.  All  these  varieties  of 
mucus  with  the  exception  of  (2)  indicate  the  presence  of  a 
catarrhal  condition  of  the  intestine. 

Intestinal  parasites  also  occur  in  the  faeces,  and  their 
discovery  may  elucidate  the  diagnosis. 

Chemical  Examination  of  the  Fceces. — The  reaction  of  the 
faeces  is  normally  neutral  or  slightly  alkaline.  Under  a 
diet  rich  in  vegetables,  however,  it  is  slightly  acid.  In 
cases  in  which  there  is  an  occlusion  of  the  bile  duct  so  that 
it  does  not  empty  into  the  intestines  the  reaction  is  strongly 
acid.  The  test  for  the  reaction  is  best  made  by  means  of 
litmus  paper.  The  reaction  at  the  surface  of  the  fecal  mat- 
ter may  be  different  from  that  in  the  interior.  It  is  there- 
fore best  to  test  both. 

The  amount  of  acidity  or  alkalinity  of  the  faeces  can  be 
determined  by  mixing  10  to  20  c.c.  of  the  fresh  fecal  matter 
with  about  100  c.c.  of  distilled  water.  A  drop  of  a  plienol- 
phthalein  solution  is  added  and  as  much  of  a  decinormal 
solution  of  either  sodium  hydrate  or  sulphuric  acid  until 
the  red  color  appears,  or  if  the  alkalinity  has  to  be  deter- 
mined, disappears.  The  reaction  of  the  faeces  is,  however, 
not  of  much  diagnostic  value. 


EXA3IINATI0N.  53 

Tests  for  Mucin. — According  to  Hoppe-Seyler,  mucin 
forms  one  of  the  principal  constituents  of  the  faeces.  In 
order  to  test  for  it  the  faeces  are  thoroughly  mixed  with 
water  and  an  equal  volume  of  milk  of  lime,  allowing  the 
mixture  to  stand  for  several  hours.  It  is  then  filtered. 
Acetic  acid  is  now  added  to  the  filtrate.  In  the  presence 
of  mucin  a  precipitate  forms.  In  case  particles  of  sus- 
pected mucus  are  visible  within  the  faeces,  they  can  be 
examined  separately  in  the  following  manner :  A  small  fiake 
of  the  mucus  is  dissolved  in  a  weak  solution  of  potassium 
or  sodium  hydrate,  and  acetic  acid  added.  If  the  precipi- 
tate remains  undissolved  after  the  addition  of  the  acetic 
acid  in  excess,  it  proves  the  presence  of  mucin.  Inasmuch 
as  nucleoalbumin  also  gives  the  reaction  just  described, 
the  positive  proof  that  the  precipitate  is  due  to  mucin  is 
afforded  by  heating  it  in  a  diluted  mineral  acid  to  the  boil- 
ing-point. If  mucin  is  present  the  heated  solution  will 
contain  a  substance  reducing  copper  oxide.  Another  very 
useful  test  for  the  presence  of  mucin  consists  in  staining 
the  flake  of  fecal  matter  resembling  mucus  with  a  weak 
triacid  solution  (Ehrlich).  The  presence  of  mucus  pro- 
duces a  green  color,  while  if  the  flake  consists  of  albumin, 
a  red  color  arises.  This  test,  first  described  by  Pariser,' 
I  have  found  of  practical  value. 

Albumin.— In  order  to  examine  the  faeces  for  albumin, 
they  are  treated  repeatedly  with  water  slightly  acidified 
with  acetic  acid.  The  watery  extract  is  filtered  several 
times  and  the  filtrate  examined  for  albumin  according  to 
the  methods  used  in  examinations  of  the  urine  for  this 
substance.  The  addition  of  acetic  acid  and  potassium  ferro- 
cyanide,  however,  is  best  suited  for  this  purpose.  Under 
normal  conditions  there  is  no  albumin  present  in  the  faeces. 
'  Pariser  :  Deutsche  inediciiiiscbe  Wochenschrift,  1893,  No.  41. 


64  DISEASES  OP  THE  INTESTINES. 

Von  Jaksch '  found  it  present  in  typhoid  fever,  in  isolated 
cases  of  acute  enteritis,  and  in  chlorosis. 

Propeptone  and  Peptone. — After  the  test  for  albumin  has 
been  made  with  negative  result,  the  watery  extract  of  the 
fseces  is  treated  with  phosphotungstic  acid,  the  precipi- 
tate diluted  with  water  and  sodium  hydrate  and  a  small 
amount  of  a  weak  solution  of  sulphate  of  copper  added. 
A  purplish-red  color  (biuret  test)  shows  the  presence  of 
both  propeptones  and  peptones.  If  it  is  desirable  to  ascer- 
tain the  presence  of  peptones  separately  it  is  necessary  to 
first  precipitate  the  propeptone  by  the  addition  of  a  large 
amount  of  ammonium  sulphate.  In  normal  dejecta  Von 
Jaksch  never  encountered  peptone.  Pathologically  he 
found  it  in  typhoid  fever,  dysentery,  tuberculous  ulcer  of 
the  intestine,  and  in  perforation  peritonitis. 

Carbohydrates.  —In  order  to  test  for  the  presence  of  car- 
bohydrates, the  faeces  are  subjected  to  distillation.  The 
residue  is  extracted  with  alcohol  and  ether ;  the  extract  is 
then  boiled  with  water,  filtered,  and  again  boiled  with  the 
addition  of  dilute  sulphuric  acid.  This  solution  is  then 
subjected  to  Trommer's  or  Ny lander's  test  for  the  presence 
of  reducing  substances. 

In  order  to  ascertain  whether  starch  is  present  the 
watery  extract  of  the  f feces  is  examined  with  Lugol's  solu- 
tion, the  presence  of  starch  producing  a  blue  color. 

If  the  dejecta  be  examined  for  the  presence  of  sugar,  then 
a  watery  extract  of  the  fecal  matter  can  be  directly  tested 
with  the  usual  sugar  reagents.  Normally  neither  starch 
nor  its  derivatives  (sugar)  are  found. 

Schmidt'  suggested  testing  the  watery  extract  of  the 
fecal  matter  with  regard  to  the  amount  of  gas  developing 

'  Von  Jaksch  :  "  Kliniache  Diagnostik. " 

» Ad.  Schmidt :  Berliner  klinische  Wochenschrift,  1898.  No.  41. 


EXAMINATION.  55 

througli  fermentation.  For  this  purpose  Schmidt  puts  the 
watery  extract  of  the  faeces  into  fermentation  tubes  (similar 
to  the  fermentation  saccharometer)  and  keeps  them  at  blood 
temperature.  The  greater  the  amount  of  gases  developing 
in  the  cylindrical  part  of  the  tube,  the  greater  the  evidence 
of  disturbances  within  the  intestine.  The  greater  propor- 
tion of  the  gas  consists  of  carbonic  acid  and  is  due  to  its 
formation  from  the  carbohydrates  existing  in  the  fecal 
matter.  In  order  to  be  able  to  judge  more  accurately  from 
this  test,  Schmidt  examined  his  patients  after  a  certain 
diet  which  they  had  been  taking  for  several  days.  It  con- 
sisted of  1,560  c.c.  of  milk,  four  eggs,  three  zwieback,  one 
plate  of  barley  soup,  one  plate  of  flour  soup,  and  one  cup 
of  bouillon  a  day.  While  Schmidt  asserts  that  whenever  a 
considerable  amount  of  gas  is  found  in  the  fermentation 
tube  this  indicates  a  real  disturbance  of  the  intestine,  S. 
Bascli,'  who  has  made  a  thorough  study  of  Schmidt's 
method  in  a  considerable  number  of  cases,  is  of  the  opinion 
that  on  the  one  hand  a  considerable  amount  of  gas  may  be 
found  in  cases  without  any  apparent  intestinal  lesion,  and, 
on  the  other  hand,  grave  disturbances  of  the  intestine  may 
show  a  total  absence  of  gas.  Inasmuch  as  Schmidt's  fer- 
mentation method  is  certainly  complicated  and  its  results 
are  not  of  great  diagnostic  value,  I  do  not  believe  that  it 
will  ever  come  into  practical  use. 

Fat. — The  presence  of  neutral  fat  and  fatty  acids  is  de- 
termined in  the  following  manner :  The  faeces  are  treated 
with  a  considerable  amount  of  ether ;  the  latter  is  separated 
and  evaporated  in  a  water  bath.  The  fat  if  present  then 
remains  and  is  visible.     In  order  to  show  the  presence  of 

'S.  Basch  •  "WelcheklinischeBedeutungbezeichnetdieSchmidt'schb 
Gillirungsprobe  der  Faeces?"  Zeitschrift  f.  klin.  Med.,  Bd.  37,  Heft 
5  and  6. 


66  DISEASES  OF  THE  INTESTINES. 

Boaps  which  do  not  dissolve  in  ether,  another  portion  of 
fecal  matter  is  iirst  treated  with  acids  which  split  up  the 
soaps  and  then  extracted  with  ether.  The  quantitative  de- 
termination of  the  amount  of  fat  and  of  its  different  com- 
ponents is  somewhat  complicated  and  of  not  much  service 
clinically.  Those  interested  in  the  subject  may  look  up 
Von  Noorden's  "Beitriige  zur  Lehre  vom  Stoffwechsel," 
Heft  I.,  p.  109,  Berlin,  1892.  Normally  fat  is  never  per- 
ceptible macroscopically  in  the  faeces  unless  after  the  in- 
gestion of  very  large  quantities.  It  may  then  be  visible  in 
small  portions  of  pea  size.  Pathologically  fat  may  exist 
in  very  large  quantities  in  the  fecal  matter  and  give  it 
a  grayish  silvery  appearance,  the  so-called  fatty  stools. 
This  normally  occurs  in  diseases  of  the  pancreas,  and  also 
whenever  the  absorption  by  the  lymphatics  is  greatly  dis- 
turbed. 

Blood. — Fresh  blood  from  the  lower  portion  of  the  intes- 
tine, and  also  from  the  higher  portions  of  the  bowel  if  pres- 
ent in  large  amount,  is  easily  recognized  by  its  macroscopic 
appearance.  Often  the  microscope  will  reveal  well-pre- 
served red  and  white  blood  corpuscles.  Sometimes,  how- 
ever, the  blood  is  changed  to  such  a  degree  that  it  is  not 
easily  recognized.  Here  various  tests  are  required  in  order 
to  prove  its  existence,  the  same  procedures  being  used  as 
for  the  discovery  of  blood  in  the  gastric  contents.  The 
hsBmin  test  which  is  chiefly  used  is  made  as  follows :  A 
small  particle  especially  suspected  of  containing  blood  is 
dried  and  powdered  and  a  portion  of  it  put  on  a  slide.  A 
trace  of  sodium  chloride  is  now  added  and  a  drop  of  glacial 
acetic  acid  poured  over  it  and  thoroughly  mixed.  A  cover- 
glass  is  now  put  over  it,  the  specimen  is  slowly  heated,  and 
after  cooling  examined  with  the  microscope.  The  presence 
of  heematin  crystals  shows  that  there  was  blood. 


EXAMINATION.  67 

Bile  Pigment — Under  normal  conditions  no  unchanged 
bile  i:)igment  is  found  in  the  faeces.  In  catarrhal  conditions 
of  the  small  intestine  it  has  been  frequently  detected.  The 
presence  of  bile  pigment  is  ascertained  in  the  following 
manner :  A  particle  of  highly  colored  fecal  matter  is  brought 
into  contact  with  a  drop  of  fuming  nitric  acid.  The  yellow 
color  usually  passes  through  the  various  colors  of  the  spec- 
trum— red,  violet  to  green.  In  some  instances  a  green 
discoloration  appears  at  once.  The  test  for  biliary  pigment 
may  also  be  made  as  follows:  The  faeces  if  liquid  are 
filtered  through  filter  paper,  and  if  not  liquid  a  watery 
mixture  is  made  and  filtered.  When  the  filter  paper  is 
dry  a  few  drops  of  nitric  acid  are  poured  on  it.  The  colors 
just  mentioned  appear  in  the  form  of  rings,  if  bile  pigment 
is  present.  Still  another  test  is  as  follows :  A  small  quan- 
tity of  the  fluid  dejecta  is  treated  with  a  concentrated 
watery  solution  of  sublimate.  If  the  faeces  contain  biliary 
pigments  in  considerable  quantity,  the  entire  mixture  turns 
green.  If,  however,  the  biliary  pigment  is  adherent  to  cer- 
tain small  fecal  particles  then  these  alone  turn  green. 

Biliary  Acids.  — Whenever  biliary  pigments  appear  in  the 
dejecta,  biliary  acids,  as  a  rule,  accompany  them.  The 
presence  of  biliary  acids  is  best  revealed  by  Pettenkofer's 
test,  and  is  made  as  follows:  A  small  quantity  of  fecal 
matter  is  thoroughly  treated  with  alcohol,  which  is  then 
evaporated.  To  the  residue  a  weak  watery  solution  of  bi- 
carbonate of  sodium  is  added,  and  to  this  mixture  a  small 
quantity  of  cane  sugar  and  a  few  drops  of  sulphuric  acid. 
When  biliary  acids  are  present  a  characteristic  red  or  pink 
color  arises. 

UrohilvK — Normally  the  biliary  pigment  within  the  in- 
testinal tract  becomes  changed  into  urobilin,  which  is  the 
principal  factor  of  the  characteristic  brownish  color  of  the 


68  DISEASES  OF  THE  INTESTINES. 

f feces.  The  best  test  for  the  presence  of  urobilin  is 
Fleischer's  '  procedure  which  is  as  follows:  A  small  quan- 
tity of  feeces  is  put  into  a  test  tube  and  a  small  amount  of 
alcohol  with  a  few  drops  of  hydrochloric  or  acetic  acid 
added;  the  mixture  is  then  left  undisturbed  for  a  short 
time.  The  presence  of  urobilin  produces  a  yellow  or 
brown  color,  the  latter,  if  present  in  large  amount.  If 
the  alcohol  is  now  poured  out  and  a  few  drops  of  sodium 
hydrate  added,  as  well  as  a  small  quantity  of  a  chloride-of- 
zinc  solution,  there  appears,  according  to  the  amount  of 
urobilin,  a  more  or  less  greenish  fluorescence  in  direct  rays 
of  light,  while  in  transmitted  light  the  fluid  appears  pink 
or  yellowish-red.  If  the  watery  extract  of  faeces  to  which 
some  ammonia  has  been  added  is  filtered  and  chloride  of 
zinc  added,  the  presence  of  urobilin  produces  a  pinkish-red 
precipitate.  If  this  precipitate  is  filtered  under  addition 
of  alcohol  containing  some  ammonia  there  appears  a  more 
or  less  greenish  fluorescence  (Schmidt's "  test).  A  small 
piece  of  fecal  matter  is  treated  with  a  concentrated  watery 
solution  of  sublimate  and  thoroughly  mixed  with  a  glass 
rod.  The  presence  of  urobilin  gives  rise  either  imme- 
diately or  a  little  later  to  a  i)inki8h-red  color,  while  biliver- 
din,  if  present,  produces  a  greenish  color. 

Normally  urobilin  is  present  in  the  faeces.  Its  absence 
is  observed  only  in  pathological  conditions. 

Acholic  Stool. — The  acholic  stool  presents  a  grayish- 
white,  ashy  gray,  or  clay  color.  It  is  usually  of  a  soft  salve- 
like consistency.  It  occurs  (1)  in  conditions  in  which 
there  is  a  total  absence  of  bile  in  the  intestine,  and  (2) 
whenever  the  absorption  of  fat  is  greatly  impaired.  Until 
very  recently  the  grayish-white  color  has  been  generally 

•  R.  Fleischer  ;  "  Krankheiten  des  Darms.  "  p.  1160,  Wiesbaden,  1896. 

*  A.  Schmidt .  Verhandlungen  des  Congresses  f .  Innere  Med. ,  1895. 


EXAMINATION.  59 

ascribed  to  the  absence  of  biliary  pigments  and  their  modi- 
fications (urobilin) ,  but  Fleischer  and  Bunge '  have  conclu- 
sively shown  that  the  whitish  color  may  be  observed  in 
faeces  containing  urobilin,  the  color  being  due  to  the  pres- 
ence of  large  amounts  of  fat.  In  the  latter  instance  the 
stool,  after  being  treated  with  large  amounts  of  ether,  thus 
separating  the  contained  fat,  assumes  a  brownish  color. 
This  I  can  confirm  also  from  my  own  experience. 

Ferments. — In  order  to  ascertain  the  existence  of  fer- 
ments in  the  pieces  a  glycerin  extract  of  them  may  be  made 
or  the  fecal  matter  may  be  directly  mixed  with  water  con- 
taining a  small  proportion  of  thymol,  and  filtered.  The 
filtrate,  or  the  glycerin  extract,  can  now  be  directly  tested 
for  the  presence  or  absence  of  the  different  ferments,  tryp- 
sin and  diastase.  In  order  to  test  for  trypsin  the  fecal 
filtrate  is  made  alkaline  by  the  addition  of  bicarbonate  of 
sodium  and  a  few  flakes  of  fibrin  are  added.  The  solution 
is  kept  at  blood  temperature  for  a  few  hours  and  then  tested 
with  potassium  hydrate  and  a  weak  solution  of  sulphate  of 
copper.  If  trypsin  is  present,  a  pinkish-red  color  will 
arise  in  consequence  of  the  peptone  which  has  formed 
(biuret  test).  In  order  to  test  for  diastase,  a  few  cubic 
centimetres  of  the  filtrate  are  mixed  with  about  half  the 
amount  of  a  starch  solution  and  kept  at  blood  temperature 
for  half  an  hour.  The  mixture  is  now  subjected  to  Fehling's 
or  Trommer's  test  for  the  presence  of  sugar.  Normally,  as 
a  rule,  these  ferments  are  absent,  but  in  pathological  condi- 
tions, especially  in  diarrhoea,  they  are  frequently  found. 

Concretions. — The  faeces  occasionally  contain  concretions 
which  may  be  of  diagnostic  importance.  In  order  to  de- 
tect them,  especially  if  they  are  small,  the  faeces  must  be 

'  Bunge  :  "  Lehrbuch  der  phys.  u.  pathol.  Chemie,  "  Leipsic,  1887, 
p.  192. 


60  DISEASES  OP  THE  INTESTINES. 

thoroughly  mixed  with  warm  water  and  poured  through  a 
large  sieve.  While  the  fecal  matter  is  on  the  sieve  some 
more  water  is  added  and  the  mass  constantly  stirred  with 
a  wooden  stick.  Any  concretions  present  will  thus  be  dis- 
covered remaining  on  the  surface  of  the  sieve. 

The  following  different  qoncretions  may  be  met  with  in 
the  faeces:  (1)  Gallstones;  (2)  pancreatic  calculi;  (3)  en- 
teroliths ;  (4)  coproliths ;  (5)  foreign  bodies. 

Biliary  calculi  are  easily  recognized  when  they  attain 
considerable  size.  AVhen  they  are  very  small,  however, 
their  recognition  is  somewhat  more  difficult.  The  princi- 
pal constituents  of  biliary  calculi  are  cholesterin  and  bile 
pigment  in  conjunction  with  lime. 

The  small  concretions  (sand)  suspected  to  be  of  biliary 
origin  should  be  examined  in  the  following  way :  About 
2  gm.  of  the  mass  is  well  powdered  and  treated  with  20 
c.c.  of  ether,  thoroughly  mixed  and  filtered,  the  filtrate 
evaporated  and  tested  for  the  presence  of  cholesterin  in  the 
following  manner :  (a)  Part  of  the  residue  is  dissolved  in 
hot  alcohol  and  put  aside  on  a  porcelain  dish  for  spontane- 
ous evaporation.  The  precipitate  is  examined  under  the 
microscope.  Crystals  of  rhomboid  shape  with  a  ragged 
edge  are  characteristic  of  cholesterin.  (b)  Another  por- 
tion of  the  residue  is  directly  put  on  a  slide,  a  drop  of 
concentrated  sulphuric  acid  added,  and  covered  with  a 
cover-glass.  The  cholesterin  crystals  assume  a  carmine 
color  at  their  margins.  If  now  a  drop  of  Lugol's  solution 
is  added  a  violet  color  arises,  (c)  Another  portion  of  the 
residue  is  treated  with  hydrochloric  acid  and  a  trace  of 
chloride  of  iron  and  evaporated.  If  cholesterin  is  present 
a  blue  color  arises.  The  residue  of  the  original  ether  mix- 
ture is  treated  with  diluted  hydrochloric  acid,  heated,  and 
extracted  with  chloroform  after  it  has  cooled  off.     The 


EXAMINATION.  61 

chloroform  extract  is  now  tested  with  Mellin's  reaction 
(fuming  nitric  acid).  The  presence  of  bile  pigment  pro- 
duces the  well-known  change  of  colors. 

Pancreatic  Calculi. — Pancreatic  calculi  usually  have  a 
rough  surface,  are  brittle,  and  may  be  faceted.  They  are 
soluble  in  chloroform  and  produce  on  evaporation  an  aro- 
matic odor  (Minich')-  Bile  pigment  and  cholesterin  are 
absent. 

Enteroliths  or  calculi  formed  in  the  small  intestine  usu- 
ally consist  principally  of  inorganic  salts  (lime,  magnesia). 
They  are  light  in  color  and  ordinarily  of  small  size.  They 
occasional!}^  form  after  an  extensive  use  of  mineral  medica- 
ments (lime,  magnesia,  etc.).  They  hardly  ever  give  rise 
to  intestinal  obstruction. 

Coproliths  or  fecal  calculi  are  found  in  the  large  bowel, 
principally  in  places  in  which  there  is  a  retardation  in  the 
passage  of  the  faeces.  Thus  th6j'  are  encountered  in  the 
caecum,  in  the  appendix,  in  sacculations  of  the  colon,  and 
in  the  rectum.  The  coproliths  are  of  stony  hardness  and 
of  sausage  shape.  They  usually  show  on  section  concen- 
tric rings.  Occasionally  they  attain  considerable  size  and 
may  give  rise  to  obstruction  of  the  bowel. 

Foreign  Bodies. — Foreign  bodies  which  have  been  swal- 
lowed ma}"  pass  through  the  entire  intestinal  tract  and  be 
eliminated  in  the  faeces.  Thus  pieces  of  bone,  coins,  mar- 
bles, needles,  and  all  kinds  of  foreign  substances  may  be 
found  in  the  stools.  In  rare  instances  concretions  of  shellac 
are  discovered  in  the  stools  of  patients  who  have  drunk 
furniture  polish,  the  shellac  forming  concretions  after  the 
absorption  of  the  alcohol.  Hair  balls  may  be  found  in 
patients  who  habitually  bite  off  and  swallow  hair. 
'Minich:  Berliner  klin.  Wochenschrift,  1894,  No.  8. 


62  DISEASES  OF  THE  INTESTINES. 

Microscopical  Examination. 

The  microscopical  examination  of  the  faeces  is  occasionally 
of  assistance  in  establishing  the  diagnosis.  With  Ewald ' 
I  do  not  think  it  necessary  to  examine  microscopically  the 
fseces  of  every  patient  presenting  intestinal  symptoms.     In 


Fio.  16.— Normal  Faeces,  sbowinga  few  Fat  Crystals  and  Fat  Globules ;  Digested  Muscle 
and  Epltbelial  Cells;  Micro-organisms. 

cases,  however,  in  which  the  diagnosis  is  not  quite  clear 
and  the  symptoms  point  to  an  intestinal  lesion,  a  micro- 
scopical examination  of  the  f feces  should  be  made. 

Diarrhoeal  stools  may  be  examined  under  the  microscope 

'  C.  A.  Ewald:   "Diseases  of  the  Intestines."    Twentieth  Century 
Practice  of  Medicine,  vol.  ix..  p.  113. 


EXAMINATION.  63 

without  any  further  preparation.  Solid  fecal  matter  is 
examined  by  taking  a  small  particle  of  the  fasces,  putting  it 
on  a  slide,  and  mixing  it  thoroughly  with  a  drop  of  physi- 
ological salt  solution.  In  order  to  avoid  the  unpleasant 
odor,  a  small  amount  of  a  watery  one-per-cent  formalin 
solution  may  be  first  added  to  the  fecal  matter.     The  micro- 


FiG.  17.— Normal  Faeces  showing  Detritus,  Plant  Cells,  Digested  Muscle  Fibres,  Bacteria. 

scopic  picture  of  the  normal  fseces  varies  greatly  according 
to  the  diet.  In  people  living  on  a  meat  diet  no  vegetable 
residue  will  be  seen,  while  there  will  be  no  remnants  of 
meat  in  people  subsisting  on  an  exclusively  vegetable  diet. 
In  case  of  a  mixed  diet  there  will  be  remnants  of  both  in 
the  stool.     A  mixed  diet  will  reveal  the  following  appear- 


64  DISEASES  OF  THE  INTESTINES. 

ances:  There  will  be  a  large  number  of  plant  cells,  the 
remnants  of  various  vegetables  and  fruits.  They  are  usu- 
ally of  considerable  size,  present  peculiar  shapes,  and  can 
be  easily  differentiated  from  animal  cells  (Figs.  16,  17,  18, 
19).  The  peels  of  pears  and  apples  and  of  prunes  com- 
monly pass  out  in  the  stool  entirely  unchanged.     Notwith- 


Fio.  18.— Dlflerent  Varieties  of  Vegetable  Cells  found  In  Normal  Faeces. 

standing  the  presence  of  these  plant  cells  in  the  stools 
starch,  as  a  rule,  is  absent.  Thus  the  microscopical  speci- 
men when  stained  with  Lugol's  solution  will  show  no  blue 
color.  If,  however,  starch  appears  in  a  stool  in  well-pre- 
served granules,  it  is  always  pathological,  indicating  de- 
ficient digestion.     Minute  fragments  of  meat  are  found 


EXAMINATION.  65 

in  small  quantity  in  the  stools.  Although  considerably 
changed  the  muscles  can  be  recognized  as  such,  and  the 
transverse  markings  can  often  be  noticed.  Frequently  they 
present  a  yellowish  tinge  from  biliary  pigment.  Connec- 
tive-tissue fibres  and  also  elastic  fibres  are  occasionally  met 


Fig.  19.— stool  of  an  Hysterical  Patient  who  Simulated  Passing  of  Lange  Quantities  of 
Mucous  Membranes  In  the  Faeces.  The  membranes  under  the  microscope  showed  the 
structure  of  common  tissue  paper ;  a  few  plant  cells,  epithelial  cells,  and  fat  crystals 
were  also  present. 

with,  both  being  quite  resistant  to  the  action  of  the  diges- 
tive juices.  The  presence  of  numerous  pieces  of  meat  in 
the  stool  is  pathological. 

Fat. — Microscopically  fat  can  be  detected  in  the  faeces  in 
the  form  of  colorless  small  globules  which  may  exist  in 


66  DISEASES   OF  THE  INTESTINES. 

large  numbers  after  an  excessive  milk  diet  or  in  the  shape 
of  small  needle-shaped  crystals,  or  again  in  the  form  of 
sheaves.  The  small  crystals  of  needle  shape  usually  occur 
singly,  and  consist  mostly  of  fatty  acids,  while  the  sheaves 
consist  of  fatty  soaps.  The  fatty-acid  crystals  melt  and 
disappear  when  heated,  while  the  soaps  remain  unchanged. 
Ether  likewise  causes  a  disappearance  of  the  fatty  acids, 
while  the  soaps  remain  unchanged.  Rieder '  suggests  the 
use  of  the  dye  stuff  Sudan  II.  (C„H,oN,0)  in  a  concentrated 
alcoholic  solution  for  the  differentiation  of  the  fats.  This 
dye  stains  plain  fat  bright  red,  while  crystals  of  iatty  acid 
and  of  lime  and  magnesia  soaps  remain  unchanged.  While 
normally  these  different  forms  of  fat  appear  in  very  scanty 
amounts  in  the  faeces,  they  may  be  found  considerably  in- 
creased under  pathological  conditions  (affections  of  the 
liver,  pancreas,  and  acute  enteritis). 

0)'ystab. — Besides  the  crystals  of  fatty  acids  and  their 
soaps  the  following  crystals  are  met  with  in  the  fssces: 
oxalate  of  lime  appears  in  the  well-known  envelope  form  of 
varying  size,  especially  after  a  diet  consisting  principally 
of  vegetables.  Calcium  carbonate  occasionally'  occurs  in  the 
form  of  amorphous  granules  or  dumbbell-shaped  crystals. 
Neutral  phosphate  of  calcium  and  ammonio-magnesium 
phosphate  crystals  are  often  present  and  can  be  readily  rec- 
ognized, the  former  occurring  in  more  or  less  well-defined 
wedge-shaped  crystals  collected  into  rosettes,  the  latter  pre- 
senting the  well-known  coffin  shape.  They  are  soluble  in 
acetic  acid.  All  the  crystals  just  mentioned  are  found  in 
normal  as  well  as  in  pathological  faeces,  and  have  no  diag- 
nostic importance.  Bismuth  crystals:  when  bismuth  is 
internally  administered  it  is  usually  found  in  the  faeces  in 

'  Rieder  :  Deutsches  Archiv  f Ur  klin.  Med. ,  1898,  Bd.  59,  Heft  3  and 
4,  p.  444. 


EXAMINATION.  67 

rhomboid  crystals  of  a  dark-brown  or  almost  black  color 
(Fig.  20).  Hsematoidin  crystals  are  occasionally  encoun- 
tered in  severe  catarrhal  conditions  of  the  intestines  or 
shortly  after  intestinal  hemorrhages  have  taken  place. 
They  occur  in  small  amorphous  particles  of  an  orange  or 


Fig.  20.— Specimen  of  Stool  of  Mrs.  W.,  living  on  Milk  Diet  and  taldng  Bismuth  and 
Magnesia.  Bismutb  and  magnesia  crystals,  some  fat  globules  and  detritus.  No  muscle 
or  plant  cells. 

ruby  red  color,  or  in  crystals  of  the  rhombic  system. 
Charcot-Leyden  crystals  of  spermiu  phosphate,  having 
the  shape  of  grains  of  oats,  are  occasionally  met  with  in 
the  faeces  and  are  of  diagnostic  importance.  According  to 
Leichtenstern, '  these  crystals  are  very  frequently  found  in 
'  Leichtenstern  :  Deutsche  med.  Wochenschrift,  1892,  No.  25. 


68  DISEASES  OF  THE  INTESTINES. 

the  fffices  whenever  intestinal  parasites  (helminthiasis) 
exist.  These  crystals,  however,  occur  also  in  other  patho- 
logical conditions  as  in  typhoid  fever,  dysentery,  tubercu- 
losis of  the  lungs.  In  rare  instances  the  Charcot-Leyden 
crystals  are  absent  in  cases  of  helminthiasis.     When  they 


Fio.  21.— Specimen  of  Stool  of  Mrs.  v.,  with  Chronic  Intestinal  Catarrh.  Groups  of  epi- 
tbeUal  cells :  detritus :  a  few  muscle  cells,  partly  digested ;  plant  cells ;  bacteria :  yeast 
cells. 

occur,  however,  they  are  an  indication  that  the  stools 
should  be  carefully  watched  for  the  presence  of  intestinal 
worms. 

Elements  Derived  from  the  Intestinal  WaU. — Epithelial 
cells  and  also  goblet  cells  occur  occasionally  in  the  fseces, 
but  only  in  scanty  number  (Fig.  21).     They  are  very  sel- 


EXAMINATION. 


69 


dom  unchanged  with  a  distinctly  visible  nucleus;  usually 
they  appear  in  a  metamorphosed  condition  without  any 
perceptible  nucleus.  Larger  accumulations  of  epithelial 
cells  may  bs  found  in  desquamative  catarrhal  conditions 
of  the  intestines. 


Fig.  22.— Stool  of  Patient  L  ,  with  .\cute  Dysentery.    Pus  cells  In  considerable  numbo; 
occasional  epitbelia ;  mucus ;  detritus. 


Blood. — Blood  in  the  f Feces  is  occasionally  easily  recog- 
nized under  the  microscope,  both  red  and  white  blood  cor- 
puscles being  i)resent.  This,  however,  is  the  fact  only  in 
hemorrhages  of  the  lower  portion  of  the  rectum.  In  hem- 
orrhages originating  in  the  upper  portion  of  the  large 
bowel  or  in  the  small  intestine,  the  blood  cells  are  usually 


70 


DISEASES  OF  THE  INTESTINES. 


already  greatly  changed  aud  not  to  be  recognized  as  such 
microscopically . 

Pus. — Pus  corpuscles  in  the  dejecta  occur  in  ulcerative 
processes  of  the  intestines  or  whenever  an  abscess  has 
discharged  its  contents  into  the  bowel.  Besides  these 
two  conditions,  it  is  also  met  with  in  dysentery.     The  pus 


Fie.  a.— stool  of  PmOent  H..  wltti  Cbroiiic  Dyseotety,  daring  an  Acute  ExacerbnOon. 
HIiMy  ■MgnMed.  Amoetw;  red  and  wblte  blood  cells :  c>7Btelso<  fat  and  ammonio- 
maKBeafiBB  pboapiiale;  plant  and  moades  cdls;  deditns. 

corpuscles  are  then  distinctly  visible  under  the  microscope 
(Figs.  22, 23, 24) .  [For  the  beautiful  execution  of  the  above 
drawings  I  am  indebted  to  Dr.  C.  A.  Elsberg  of  this  city.] 
Jfi/CM*. — Mucus  is  frequently  seen  in  the  dejecta  under 
the  microscope.     It  is  recognized  by  its  thread-like  ap- 


EXAMINATION. 


71 


I)€araiice  (Fig.  25).  Occasionally  it  is  also  amorphons. 
Thionin  colors  maciis  reddish-violet,  while  it  stains  other 
proteid  substances  blue.  Mucus  is  often  present  in  ca- 
tarrhal conditions  of  the  intestine  and  also  in  membranous 
enteritis. 
Pieces  of  Tumors. — In  rare  instances  a  smaU  fragment  of 


Fig.  21.— From  tlie  Sune  Patienu  a  Few  Days  Laio-.    HiglilT 
inglobalesuidarTBtslB;  a  few  red  and  wliite  Mood  cwpuadei: 
tns;  bacteria. 


Amoetae:  fit 
■nadea cells;  detzi- 


tumor  may  be  found  in  the  dejecta.  Under  the  microscope 
the  structure  of  the  mass  will  be  seen  and  its  character  de- 
termined. The  result  of  such  an  examination  may  be  of 
great  diagnostic  importance. 

Micro-organisms. — Numerous  micro-organisms  are  found 


72 


DISEASES  OP  THE  INTESTINES. 


in  the  faeces  normally  as  well  as  pathologically.  Their 
number  averages  in  daily  evacuations  fifty -three  milliards. 
Sometimes  they  may  reach  as  high  a  figure  as  four  hundred 
milliards.  Beginning  with  the  stomach  the  number  of 
micro-organisms  steadily  increases  all  through  the  intesti- 
nal tract  down  to  the  large  bowel,  where  the  maximum  is 


Fio.  25.— Specimen  of  the  Stool  of  Mrs.  J.  B.,  Suffering  from  Intestinal  Catarrh.  Mucus 
all  over  the  Held  of  vision ;  a  few  plant  cells  and  muscle  cells,  and  an  occasional  fat 
crystal. 

reached.     The  micro-organisms  appear  to  be  intimately 

connected  with  the  physiological  processes  of  digestion. 

This  is  true  notwithstanding  the  valuable  investigations  of 

Nencki,  Macfadyen,  and  Sieber,'  and  Thierf elder  and  Nut- 

•Nencki,  Macfadyen,  und  Sieber:  Archiv  f.  experimentelle  Patho- 
logic u.  Pharmakologie,  Bd.  28,  S.  301. 


EXAMINATION.  73 

tal,'  which  have  shown  that  normal  digestion  is  possible 
even  without  bacteria.  Pathologically  various  kinds  of 
bacteria  play  a  very  important  part.  Besides  certain  spe- 
cies of  pathogenic  bacteria,  the  micro-organisms  normally 
sojourning  in  the  intestine  occasionally  assume  morbific 
properties. 

The  different  varieties  of  micro-organisms  in  the  intes- 
tinal tract  have  been  thoroughly  studied  by  Mannaberg,^ 
who  found  fourteen  different  species  of  bacilli,  nine  species 
of  micrococci,  and  four  species  of  schizomycetes.  Of  the 
latter  saccharomyces  cerevisiae  are  most  frequently  encoun- 
tered in  the  faeces.  They  are  found  in  groups  forming 
three  or  four  buds,  and  assume  a  mahogany  color  when 
treated  with  Lugol's  solution.  Of  the  bacteria  and  cocci 
the  following  deserve  special  mention : 

The  bacterium  coli  commune,  first  described  by  Esche- 
rich, '  occurs  in  the  form  of  thin  or  thick  rods  being  about 
0.4  //  in  length.  Some  show  motile  power.  They  are  well 
stained  by  the  ordinary  anilin  dyes  and  decolorized  by 
Gram's  solution.  Their  colonies  growing  upon  gelatin  re- 
semble those  of  the  bacillus  of  typhoid  fever. 

The  bacterium  lactis  aerogenes  (Escherich)  greatly  re- 
sembles the  bacterium  coli  commune.  It  is  frequently 
found  in  the  stools  of  infants,  and  is  now  and  then  met  with 
in  those  of  adults.  It  is  found  in  thick  rods  frequently 
lying  in  pairs.  They  are  non-motile  and  have  the  property 
of  causing  fermentation  of  milk,  producing  coagulation  and 
formation  of  gas  within  sixty  hours. 

•  Tbierfelder  u.  Nuttal  Zeitscbrift  f.  phys.  Cheinie,  Bd.  21,  S.  109, 
u.  Bd.  22,  S.  62. 

*  Mannaberg  :  "  Die  Bacterien  des  Darms  "— Notbnagel's  Erkrankun- 
gen  des  Darms,  Wien,  1895. 

3  Escbericb  :  "  Beitrage  zur  Kenntniss  der  Darmbacterien.  "  MUnch- 
ener  med.  Wocbenscbr. ,  1886.  No   i..  43-45. 


74  DISEASES  OP  THE  INTESTINES. 

BaciUm  putrificua  coli  (Bienstock')  forms  slender  rods 
3  II  in  length.  This  bacillus  energetically  decomposes 
proteid  substances  in  presence  of  air  under  the  formation 
of  ammonia,  amin  bases,  fatty  acids,  tyrosin,  phenol,  indol. 

While  all  the  above-mentioned  micro-organisms  give  a 
mahogany  or  brown  color  with  solutions  of  iodine,  there 
are  a  few  varieties  which  give  a  blue  color  with  this  sub- 
stance. To  the  latter  belongs  the  bacillus  butyricus  de- 
scribed by  Nothnagel."  It  is  rod-shaped,  3  to  10  fj.  long 
and  1  /^  thick.  It  is  often  lemon-shaped.  This  bacillus 
is  anaerobic  an(J  produces  fermentation  of  starch,  sugar, 
and  cellulose,  forming  butyric  acid  and  gas.  The  bacillus 
butyricus  is  often  found  in  pathological  conditions  of  the 
intestine,  but  occurs  in  small  numbers  also  in  normal  faeces. 

Of  the  pathogenic  micro-organisms,  cholera,  typhoid,  and 
tubercle  bacilli  are  found  in  the  faeces.  The  cholera  and 
typhoid  bacilli  causing  infectious  diseases  do  not  belong, 
strictly  speaking,  to  the  micro-organisms  producing  dis- 
eases of  the  intestine  alone.  The  tubercle  bacilli,  occasion- 
ally producing  intestinal  tuberculosis,  are  recognized  in  the 
f feces  by  the  same  methods  which  are  employed  in  the 
examination  of  the  sputum. 

TREATMENT. 

Diet 

The  principles  of  diet  are  fully  described  in  my  book  on 

the  stomach.     Here  I  will  add  a  few  remarks  referring  to 

the  dietetic  treatment  of  intestinal  diseases.     As  in  the 

case  of  the  stomach,  acute  intestinal  disorders  lasting  a 

'  B.  Bienstock  :  "Ueber  die  Bacterien  der  Faeces.  "  Zeitschr.  f.  klin. 
Med..  Bd.  8.  1884. 

*H.  Nothnagel :  "Die  normal  in  dem  !Menschendarm  vorkommenden 
niedereten  (pflanzlichen)0rgani8men."  Zeitschr.  f.  klin.  Med.,  Bd.  3. 
1881. 


TREATMENT.  75 

few  days  or  weeks  must  be  managed  according  to  the  prin- 
ciple of  rest.  Very  scanty  and  light  foods  (mostly  liquid) 
should  be  given.  In  chronic  ailments  of  the  intestines  the 
principle  of  rest  may  also  be  utilized  occasionally  for  a 
short  time,  while  as  a  general  rule  we  should  bear  in  mind 
the  necessity  of  introducing  sufficient  quantities  of  food 
and  gradually  accustoming  the  intestinal  tract  to  the  ordi- 
nary foods. 

In  some  instances  it  is  possible  to  exert  a  wholesome 
influence  upon  the  disturbances  of  the  intestine  by  appro- 
priate dietetic  measures.  This  applies  especially  to  dis- 
orders accompanied  by  constipation  or  by  diarrhoea. 

I.  Articles  of  diet  ivhich  increase  ijie  intestinal  peristalsis 
or  "^ laxative  foods ''  are  the  following:  Most  fruits,  both' 
raw  and  cooked,  and  fruit  juices  increase  the  peristalsis 
in  consequence  of  the  organic  acids  which  they  contain,  as 
apples,  pears,  plums,  i^eaches,  strawberries,  gooseberries, 
dates,  and  figs.  Most  salads  and  garden  vegetables  also 
increase  peristalsis,  firstly,  owing  to  the  large  amount  of 
water  they  contain,  and  secondh',  owing  to  the  consider- 
able residue  which  is  left  undigested,  as,  for  instance, 
melons,  cucumbers,  tomatoes,  pumpkins,  all  kinds  of  cab- 
bage. By  many  of  the  latter  foods  the  peristaltic  action 
of  the  intestine  is  also  increased  on  account  of  the  forma- 
tion of  acid  and  gaseous  products.  Fresh  beer,  cider, 
bonny-clabber,  and  kumyss  act  in  a  similar  manner.  Cold 
drinks  of  plain  water  or  carbonated  water  act  as  mild  ape- 
rients in  some  instances.  Here  a  reflex  action  upon  in- 
testinal peristalsis  due  to  irritation  must  be  assumed,  for 
often  a  movement  of  the  bowels  follows  very  soon  (a  (juar- 
ter  of  an  hour  to  one  hour)  after  drinking. 

II.  Articles  of  diet  which  diminish  the  intestinal  peri- 
stalsis or   "constipating  foods":    (1)  All  substances  con- 


76  DISEASES  OF  THE  INTESTINES. 

taining  a  considerable  portion  of  astringent  agents,  par- 
ticularly tannic  acid,  as,  for  instance,  dried  bilberries, 
French  red  wines  (particularly  San  Rafael  wines),  tea,  ca- 
cao, the  acorn  preparations  like  acorn  coffee,  acorn  cacao. 
(2)  Foods  which  have  a  mucilaginous  character  and  thus 
somewhat  allay  irritation  also  have  a  slightly  constipating 
effect:  sago,  tapioca,  barley,  rice.  (3)  Foods  which  leave 
no  residue  whatever  or  very  little  residue,  and  thus  exert 
no  irritation.  To  these  belong  egg  water  (prepared  by  dis- 
solving the  white  of  an  egg  in  some  water),  scraped  raw 
meat,  mutton  broth. 

Some  foods  manifest  different  action  in  different  individ- 
uals. Thus,  for  instance,  milk  is  constipating  in  one  per- 
son and  laxative  in  another,  while  in  still  others  it  has  no 
special  effect  upon  intestinal  peristalsis. 

Most  foods  have  no  marked  influence  upon  the  intestinal 
peristalsis.  To  these  belong  most  kinds  of  meat  and  fish 
not  too  highly  seasoned,  the  various  meat  powders,  and 
most  artificial  foods  like  meat  peptone  and  nutrose,  eucasin, 
somatose,  sanose,  eggs  prepared  in  different  ways,  well- 
baked  bread,  wheaten  or  rye  bread,  crackers,  zwieback, 
fats  in  small  amounts,  especially  butter.  The  preparation 
of  the  foods  has  an  important  bearing  with  regard  to  its 
action  upon  the  intestinal  peristalsis.  The  finer  the  foods 
are  the  less  irritating  they  will  act,  and  the  coarser  the 
imrticles  the  greater  the  irritation  they  produce  upon  the 
intestinal  muscular  layer.  Highly  seasoned  foods  also  act 
as  a  stimulant  of  the  peristalsis. 

In  some  severe  conditions  of  the  intestines  the  ordinary 
way  of  ingestion  of  food  must  be  avoided  for  a  short  period. 
Here  artificial  feeding  is  employed.  Artificial  feeding  can 
be  done  in  two  different  ways:  rectal  alimentation  and 
subcutaneous  alimentation. 


TREATMENT.  77 

1.  Rectal  Alimentation. — The  rectum  and  the  greater 
part  of  the  large  bowel  should  be  emptied  if  possible  be- 
fore injecting  the  feeding  enema.  The  latter  is  best  accom- 
plished by  using  a  fountain  syringe  and  a  soft-rubber  tube 
which  is  introduced  for  about  five  to  seven  inches  into  the 
rectum.  Tlie  quantity  of  the  feeding  enema  may  be  be- 
tween five  and  ten  ounces.  As  feeding  enemas  the  follow- 
ing substances  are  used :  («)  The  different  kinds  of  pep- 
tones and  propeptones  in  the  market  of  which  about  two 
to  three  ounces  can  be  dissolved  in  six  to  eight  ounces  of 
water.  The  different  beef  juices  may  also  be  dissolved  in 
water  and  injected  in  corresponding  quantities,  (b)  The 
milk  and  egg  enemas.  These  are  mostly  used.  Their 
composition  is  as  follows :  Six  to  seven  ounces  of  milk, 
one  or  two  raw  eggs  well  beaten  up,  one  teaspoonful  of 
powdered  sugar,  and  the  point  of  a  kuifeful  of  salt.  The 
addition  of  pancreatin  (one  tube  of  Fairchild  pancreatin 
to  one  enema)  will  facilitate  assimilation,  (c)  Meat-pan- 
creas enema.  Leube  '  employs  enemas  consisting  of  well- 
chopped  meat  mixed  with  fresh  pancreas. 

Besides  these  food  enemas  injections  of  water. into  the 
bowel  are  made  in  order  to  increase  the  amount  of  fluid  in 
the  system.  These  injections  of  water  for  the  purpose  of  ab- 
sorption are  of  great  importance.  Usually  saline  solutions 
are  employed  in  quantities  varying  from  one  pint  to  one 
quart.  The  nutritive  enema  should  be  given  three  or  four 
times  in  twenty-four  hours,  and  the  water  enemas  for  ab- 
sorption once  or  twice  a  day. 

2.  SubcufaneoHs  Alimentation. — In  diseases  of  the  intes- 
tine special  conditions  are  met  with  in  which  neither  the 
ordinary  way  of  feeding  nor  rectal  alimentation  is  possible. 

'Leube:  Leyden's  "Handbuch  der  Ernahrungstherapie, "  Bd.  i.,  p. 
508,  Leipsic,  1897. 


78  DISEASES  OF  THE  INTESTINES. 

Here  an  attempt  must  be  made  to  introduce  nourishment 
subcutaneously.  Most  food  substances  cannot  be  intro- 
duced under  the  skin  without  inflicting  more  or  less  injury. 
Two  substances  onlj*  form  an  exception  and  are  of  practical 
value :  (a)  Olive  oil.  This  can  be  injected  subcutaneously 
to  the  amount  of  one  ounce  twice  or  three  times  a  day.  It 
is  hardly  necessary  to  say  that  the  oti  as  well  as  the  syringe 
used  for  this  purpose  should  be  thoroughly  sterilized.  A 
large-sized  Pravaz  syringe  is  employed,  and  but  little 
pressure  exerted  while  injecting.  This  precaution  is  neces- 
sary in  order  to  obviate  any  traumatism  (tearing)  of  the  tis- 
sues. The  best  place  for  the  injection  is  the  thigh.  (6) 
Water.  A  saline  solution  is  subcutaneously  injected  in 
amounts  var3'ing  from  one  pint  to  a  quart.  This  serves  to 
increase  the  amount  of  fluid  in  the  system.  The  injection 
is  made  by  means  of  the  fountain  syringe  to  the  end  of 
which  an  aspirating  needle  is  attached.  The  same  pre- 
cautions as  above  are  necessary.  The  saline  injection 
may  be  employed  twice  or  three  times  a  day  if  necessary. 

Mechanical  Procedures. 

Injections. — Injections  into  the  bowel  in  the  form  of  clys- 
ters were  used  for  curative  purposes  even  in  old  times. 
The  regular  syringe  with  its  stiff  end  may,  if  forcibly  in- 
serted, give  rise  to  damage  of  the  rectum.  For  this  reason 
nowadays  a  soft-rubber  rectal  tube  is  employed,  to  which 
a  fountain  or  Davidson  syringe  or  any  form  of  syringe  can 
be  attached.  The  tube  being  flexible  cannot  injure  the  in- 
testinal walls.  It  can  also  be  introduced  higher  up  than 
the  ordinary  hard-rubber  end  pieces  of  the  fountain  syringe. 
Instead  of  the  fountain  syringe  a  funnel  apparatus  similar 
to  the  one  used  in  gastric  lavage  may  be  employed.  For 
washing  out  the  bowel  Leube-Rosenthal's  appliance  for 


TREATMENT.  79 

washing  out  the  stomach  can  be  used  to  advantage.  For 
irrigation  of  the  bowel  Kemp's  hard-rubber  rectal  double- 
current  irrigator  can  be  conveniently  emploj^ed  (Fig.  26). 

These  injections  into  the  bowel  are  made  for  various 
purposes : 

1.  To  produce  an  evacuation.  About  a  quart  of  luke- 
warm water  to  which  a  teaspoonful  of  salt  is  added  can 
be  employed,  or  a  piece  of  soap  dissolved  in  the  same 


Fig.  26.— Dr.  R.  C.  Kemp's  Rectal  Irrigator  (New  Model).  Outer  tube  of  hard-rubber; 
central  tube  of  metal.  Hard-rubber  flange,  protecting  sphincter  from  transmission  of 
beat  through  the  metal  parts. 

-amount  of  water.  As  a  rule,  it  is  not  advisable  to  intro- 
duce larger  quantities  of  water  than  these  as  they  distend 
the  bowel  too  much.  In  greatly  atonic  conditions,  how- 
ever, in  which  a  quart  of  water  may  be  inefficient,  an 
injection  of  from  two  to  three  quarts  will  be  required.  In- 
jections of  oil  (olive  oil  or  sesame  oil)  in  quantities  varying 
from  half  a  pint  to  one  pint  have  been  recommended  by 
Fleiner.'  According  to  this  writer  the  oil  should  be  in- 
jected at  blood  temperature  into  the  rectum  when  retiring 
and  be  retained  over  night.  While  olive  oil  was  used  as  a 
laxative  injection  long  ago  by  Habershon '  and  others,  we 
owe  its  methodical  use  to  Fleiner,  to  whom  is  also  due  the 
credit  for  having  promulgated  the  method.  Small  injec- 
tions of  glycerin  (one  or  two  drachms)  in  about  an  ounce 

'Fleiner:  "Ueber  die  Behandlung  der  Constipation."    Berl.  klin. 
Wochenschr. ,  1893,  Nos,  3  and  4. 
'Habershon.  "Diseases  of  the  Abdomen,"  London,  1862. 


80  DISEASES  OF  THE  INTESTINES. 

of  water  can  also  be  advantageously  employed  for  produc- 
ing an  evacuation  of  the  bowels. 

2.  Injections  may  be  resorted  to  either  to  strengthen 
the  tonicity  of  the  bowel,  in  which  case  plain  very  cold 
water  in  amounts  of  from  one  to  two  quarts  can  be  em- 
ployed, or  for  medicinal  purposes,  i.e.,  for  applying  cer- 
tain medicaments  directly  to  the  intestinal  mucosa.  The 
drugs  most  frequently  used  for  this  purpose  are  nitrate  of 
silver,  tannic  acid,  subnitrate  of  bismuth,  as  astringents; 
thymol,  hydrogen  peroxide,  boracic  acid,  essence  of  pep- 
permint, as  disinfectants. 

Massage  and  Gymuastic  Exercises. — Massage  is  frequently 
employed  in  functional  diseases  of  the  intestine.  Its  field 
of  usefulness  lies  principally  in  neurotic  and  atonic  condi- 
tions. Massage  should  be  applied  by  well-trained  and 
experienced  persons.  Abdominal  massage  requires  great 
care,  as  too  rough  manipulation  is  liable  to  do  great  harm. 
Gymnastic  exercises  and  sports  are  well  adapted  to  stimu- 
late and  strengthen  the  muscles  of  the  abdomen  as  well  as 
those  of  the  intestine.  Ewald  particularly  recommends 
rowing  in  boats  with  sliding  seats  as  an  exercise  which 
gives  definite  results  in  chronic  intestinal  torpidity.  Golf, 
billiards,  horseback  riding,  bicycle  riding,  walking  may 
also  be  included  among  the  exercises  contributing  to  a  ton- 
ing up  of  the  system. 

Hydrotherapy. — Moist  applications  in  the  form  of  either 
Priessnitz's  compresses  or  poultices  are  often  of  benefit. 
Priessnitz's  compresses  are  stimulating,  while  the  warm 
fomentations  serve  as  a  sedative.  The  latter  are  applied 
to  allay  pain,  the  heat  producing  a  temporary  paralysis  of 
the  superficial  sensory  nerves.  Instead  of  either  cold  or 
warm  compresses  a  rubber  bag  filled  with  either  cold  or 
hot  water  may  be  applied.     When  warm  applications  are 


TREATMENT. 


81 


required  they  can  also  be  used  in  the  form  of  the  Japanese 
box.  Sitz  baths  of  various  temperatures  may  be  employed. 
A  shower  bath,  especially  over  the  abdomen,  of  cold  or 
warm  water  or  of  alternating  cold  and  warm  water,  is  also 
of  benefit.  Man}'  of  these  procedures  may  be  combined 
with  massage,  and  in  this 
way  the  curative  action 
is  enhanced. 

Electricity. — The  fara- 
dic,  galvanic,  or  frank- 
linic  currents  are  em- 
ployed. All  these  three 
can  be  used  percuta- 
neously;  the  first  two 
also  intrarectally.  The 
faradic  current  is  mostly 
applied  in  atonic  condi- 
tions of  the  bowel  with 
the  object  of  stimulating 
the  motor  function  of  the 
intestines.  The  galvanic 
current     i  s     principally 

emploj'ed  in  painful  intestinal  affections  of  neurotic  char- 
acter. The  franklinic  or  static  current  may  be  advan- 
tageouslj'  used  in  both  conditions.  For  the  intrarectal 
application  of  the  current  I  use  an  electrode  which  in  prin- 
ciple is  very  similar  to  that  of  Boudet '  and  consists  of  a 
perforated  hard-rubber  end  piece  in  which  is  lodged  a 
metallic  button  connected  by  means  of  a  wire  with  the  bat- 
tery. To  the  upper  end  of  the  hard-rubber  piece  is  at- 
tached a  soft-rubber  tube  leading  to  an  irrigator  and  pro- 

'  Boudet:   Cited  after  A.  Mathieu :  "Treatment  of  Diseases  of  the 
Stomach  and  Intestines,  "  New  York,  1894,  p.  171. 
6 


FIG.  27.-R«>tal  Electrode. 


82  DISEASES  OF  THE  INTESTINES. 

vided  with  a  stopcock  (see  Fig.  27).  Proceed  as  follows: 
The  irrigator  is  filled  with  water  at  blood  temperature. 
The  hard-rubber  piece,  or  the  rectal  electrode,  is  smeared 
with  vaseline  and  introduced  into  the  rectum.  Another 
plate  electrode  is  moistened  and  placed  over  the  abdomen, 
the  stopcock  partly  opened,  and  the  current  applied.  The 
water  running  from  the  end  piece  of  the  electrode  into  the 
bowel  carries  the  electricity  along  vdth  it.  The  electrical 
application  should  last  from  five  to  ten  minutes,  the 
amount  of  water  used  varies  from  ten  to  fifteen  ounces. 
The  outflow  of  ttie  water  can  be  regulated  by  the  stopcock 
arrangement.  I  have  applied  both  the  faradic  and  gal- 
vanic currents  with  this  apparatus  and  found  it  very  con- 
venient. The  faradic  current  may  be  applied  as  strong  as 
the  patient  can  bear,  while  the  galvanic  current  should  be 
used  with  the  negative  pole  in  the  rectum,  the  intensity 
of  current  ranging  from  eight  to  fifteen  milliamperes. 


CHAPTER  III. 

ACUTE  AND  CHRONIC    INTESTINAL  CATARRH. 

ACUTE  INTESTINAL  CATARRH. 

Spwmjms :  Enteritis  acuta;  Catarrhus  intestinalis  acu- 
tus ;  Acute  diarrlia?a ;  Cholera  nostras. 

Dejinition. — An  inflammatory  affection  of  the  intestines 
characterized  by  a  sudden  development  of  pains  and  more 
or  less  loose  movements. 

Etiology. — Acute  intestinal  catarrh  is  one  of  the  most 
frequent  diseases.  AVhile  it  occurs  more  often  in  infants 
and  children  it  is  found  in  i>ersons  of  all  ages. 

The  affection  may  attack  the  entire  intestinal  tract  or 
may  be  limited  to  a  part  of  it.  Thus  we  may  have  a  duo- 
denitis, jejunitis,  ileitis,  typhlitis,  colitis,  and  proctitis 
(inflammation  of  the  rectum) .  With  regard  to  frequency 
the  colon  is  most  often  affected.  According  to  Woodward, ' 
an  inflammation  of  the  small  intestine  alone  hardly  ever 
exists,  a  poiiiou  of  the  large  bowel  always  being  affected. 
Intestinal  catarrh  is  either  primary  (idiopathic)  or  second- 
ary when  occuiTing  as  a  sequel  of  other  diseases.  Acute 
enteritis  may  be  due  to  a  number  of  causes : 

1.  It  may  result  from  the  ingestion  of  heavy  indigestible 
food,  ice-cold  drinks,  and  tainted  meat  or  fish,  unrii)e  fruit, 
stale  or  sour  beer,  bad  water. 

2.  Good  food  and  drink  taken  in  unusually  large  quanti- 
ties may  also  produce  this  condition. 

'  Woodward  :  "The  Medical  and  Surgical  History  of  the  War  of  the 
Rebellion, "  vol.  i  ,  part  2. 


84  DISEASES  OF  THE  INTESTINES. 

3.  A  host  of  organic  and  inorganic  substances  may  chem- 
ically irritate  the  intestinal  mucosa  and  cause  inflammation. 
All  the  drastic  remedies,  like  croton  oil,  colocynth,  jalap, 
etc. ,  belong  to  these  organic  irritating  substances ;  of  the 
inorganic  may  be  mentioned  tartar  emetic,  arsenic,  lead, 
sulphate  of  copper,  all  the  mercurial  preparations,  concen- 
trated acids,  and  strong,  caustic  alkalies. 

4.  Enteritis  may  be  caused  by  mechanical  irritants. 
Thus  hardened  scybala,  biliary  calculi,  enteroliths,  or 
foreign  bodies  which  have  been  swallowed,  like  large  ker- 
nels of  fruit  or  coins,  may  evoke  inflammation.  The 
catarrh  accompanying  intestinal  worms  may  also  be  placed 
in  this  groujj. 

6.  Intestinal  catarrh  is  very  often  due  to  variations  in 
temperature  or  to  catching  cold.  It  seems  that  the  dispo- 
sition to  this  agent  varies  in  different  individuals.  Thus 
some  i^eox^le  get  an  attack  of  diarrhoea  if  they  sleep  uncov- 
ered during  the  summer  and  a  drop  in  temperature  occurs, 
the  colder  atmosphere  affecting  the  abdomen.  Others, 
again,  are  attacked  with  diarrhoea  whenever  they  get  their 
feet  wet.  How  the  influence  of  cold  acts  in  causing  the 
enteritis  is  difl&cult  to  say.  Some  writers  believe  that  the 
sudden  change  in  the  circulation  of  the  blood  caused  by 
the  cold  is  the  principal  factor;  others  again  explain  it  on 
the  ground  of  a  more  favorable  development  of  micro- 
organisms during  the  change  of  temperature. 

6.  Auto-intoxication.  Poisonous  substances  may  develop 
in  the  intestinal  tract  and  cause  diarrhoea.  The  enteritis 
following  large  bums  of  the  skin  belongs  to  this  group. 
Here  the  poisonous  substance  is  probably  formed  at  the 
site  of  the  burned  skin  and  carried  by  the  blood  current 
into  the  intestinal  tract. 

Secondary  catarrh  of  the  intestine  occurs  in  almost  all 


ACUTE  INTESTINAL  CATARRH.  85 

acute  infectious  diseases  in  the  same  way  as  gastric  catarrh. 
It  is  further  found  accompanying  heart,  kidney,  and  liver 
diseases,  tuberculosis,  diabetes,  etc.  Most  organic  dis- 
eases of  the  bowels  are  associated  with  intestinal  catarrh, 
as  cancer  of  the  intestines,  volvulus,  invagination,  peri- 
tonitis, thrombosis.  In  this  class  of  cases,  however,  the 
intestinal,  catarrh  is  of  little  importance  compared  with  the 
primary  affection. 

Morbid  Anatomy. — The  anatomical  changes  found  in  au- 
topsies are  not  always  very  well  marked,  and  there  is  cer- 
tainly no  exact  relation  between  the  intensity  of  the  clinical 
symptoms  and  the  severity  of  the  pathological  processes 
discovered.  The  mucous  membrane  of  the  affected  part 
of  the  intestine  appears  reddened  either  over  its  entire  ex- 
tent or  only  in  spots.  This  red  color  is  more  pronounced 
around  the  follicles  and  i^atches,  at  the  apex  of  the  folds 
and  of  the  villi.  If  the  process  is  intense,  extravasations 
of  blood  may  be  found.  The  mucous  membrane  appears 
swollen,  sometimes  cedematous,  often  it  is  covered  with 
tenacious  mucus.  The  villi  and  the  solitary  follicles  are 
succulent  and  appear  as  whitish,  small  prominences  sur- 
rounded by  a  red  stratum  (enteritis  follicularis  seu  nodu- 
laris). If  the  process  continues,  these  gray  areas  may 
rupture,  and  thus  give  rise  to  ulcerative  lesions  (follicular 
ulcers) .  Catarrhal  ulcers  also  exist,  however,  caused  by 
the  loss  in  some  places  of  the  protective  epithelial  covering 
of  the  mucosa.  Through  extension  of  the  inflammation  in 
width  and  depth  irregular  losses  of  substance  with  under- 
mined edges  are  produced.  Inflammatory  irritation  in  the 
neighborhood  of  these  defects  may  give  rise  to  polypoid 
growths,  especially  when  the  process  has  run  a  protracted 
course. 

Microscopically   the  vessels  of    the  mucosa  and  sub- 


86  DISEASES  OF  THE  INTESTINES. 

mucosa  appear  in  a  more  or  less  congested  state.  Small 
extravasations  often  exist  between  the  glands  of  Lieber- 
kuehn.  The  spaces  between  the  glands  are  frequently 
widened  and  filled  with  an  abundant  accumulation  of  round 
cells.  The  epithelium  of  the  mucosa  has  mostly  disap- 
peared, especially  in  the  large  bowel.  But  according  to 
Nothnagel  this  may  be  a  post-mortem  phenomenon  and  not 
always  the  result  of  inflammation.  Desquamative  processes 
in  the  epithelial  layer,  however,  occur  during  life  caused 
by  the  catarrhal  affection,  for  the  changed  eroded  epithelial 
cells  are  found  in  the  mucus  voided  with  the  stool.  The 
glands  often  appear  altered  with  regard  to  their  contour, 
being  wider  at  their  fundus  and  much  narrower  at  their 
mouth,  frequently  presenting  a  flask  shape.  The  sub- 
mucous tissue  is  usually  somewhat  hyperplastic,  otherwise 
not  much  changed.  The  muscular  and  serous  coats  are 
not  affected. 

Symptomatology. — Intestinal  catarrh  usually  manifests 
itself  through  a  feeling  of  fulness  in  the  lower  part  of  the 
abdomen,  colicky  pains  appearing  from  time  to  time,  and 
diarrhoea.  As  a  rule,  no  fever  is  present  except  in  cases  of 
a  severe  type.  The  number  of  the  stools  and  their  quality 
vary  a  great  deal.  In  mild  cases  there  may  be  only  two  or 
three  movements  in  twenty-four  hours;  in  severer  cases 
fifteen  to  twenty  diarrhceal  evacuations.  The  first  passage 
as  a  rule  still  contains  normal  fecal  matter  in  its  first  por- 
tion, while  the  second  part  is  of  a  mushy  character.  The 
next  movements  are  semi-fluid,  and  at  last  entirely  liquid 
dejecta  may  appear.  The  first  stool  still  has  a  brown  color 
and  the  characteristic  fecal  odor,  while  the  following  evac- 
uations present  a  slightly  yellowish  color  or  even  a  grayish 
appearance,  occasionally  resembling  rice-water.  The  latter 
are  sometimes  devoid  of  fecal  odor,  have  an  acid  reaction, 


ACUTE  INTESTINAL  CATARRH.  87 

and  show  a  foamy  surface.  Mucus  is  almost  always  pres- 
ent. The  fecal  matter  in  its  yellow  parts  contains,  as  a 
rule,  unchanged  biliary  substances  which  give  a  charac- 
teristic Gmelin  reaction.  Microscopically  undigested  food 
particles  may  be  discovered  in  larger  than  normal  amounts; 
thus  meat  fibres  and  well-preserved  granules  of  starch 
may  be  observed.  A  host  of  micro-organisms,  epithelial 
cells,  sometimes  in  contiguous  groups,  and  mucus  are 
found.  Very  seldom  and  only  in  severer  cases  small 
amounts  of  pus  and  red  blood  corpuscles  may  be  dis- 
covered. Chemically  peptones  and  sugar  may  be  found  in 
the  dejecta. 

General  Subjective  Symptoms. — Aside  from  the  dian-hceal 
movements  and  the  unpleasant  sensations  consisting  in  a 
feeling  of  pressure  and  fulness  in  the  abdomen  mentioned 
above,  there  may  in  light  cases  be  perfect  euphoria ;  usu- 
ally a  feeling  of  weakness  exists  which  is  especially  marked 
in  the  lower  extremities.  A  feeling  of  dizziness  and  slight 
nausea  often  also  appear,  especially  shortly  before  and 
during  evacuations.  Vomiting  may  also  occur,  as  a  rule,  in 
cases  in  which  the  stomach  is  likewise  affected  or  when  the 
process  of  inflammation  is  of  a  severer  type  (cholera  nos- 
tras). Tenesmus  is  frequently  present,  if  the  process  is 
in  the  lower  part  of  the  colon,  even  if  not  especially  pro- 
nounced. This  seems  to  be  the  result  of  the  irritating 
action  of  the  dejecta  upon  the  rectum. 

The  general  symptoms  above  described  are  much  more 
pronounced  in  children  and  very  old  people.  Here  the 
appearance  of  collapse  (cold  extremities,  blue  lips,  and 
apathy)  is  not  very  rare.  Marshall  Hall '  has  described  a 
condition  under  the  name  of  acute  hydrocephaloid  disease 

'  Marshall  Hall :  "  Diseases  and  Derangements  of  the  Nervous  Sys- 
tem,"  London,  1841,  p.  153. 


88  DISEASES  OP  THE  INTESTINES. 

which  occurs  in  weak  children  with  acute  enteritis.  The 
hydrocephaloid  appears  in  consequence  of  severe  attacks  of 
gastro-enteritis  with  a  temperature  of  104°-106°  F.  There 
is  sudden  collapse.  While  the  body  is  hot,  the  extremi- 
ties become  ice  cold,  the  fontanelles  sink  in,  the  pulse 
becomes  considerably  accelerated,  soft,  and  often  irregular. 
In  this  condition  the  little  patient  lies  apathetic  unless 
suddenly  disturbed  with  colicky  pains  when  he  utters  a 
cry.  The  pupils  do  not  react  alike  and  the  conjunctival 
reflex  may  be  absent.  Sometimes  paralysis  of  the  rectum 
is  present,  which  I  have  seen  in  one  case.  In  this  condi- 
tion the  patient  often  dies  within  a  short  time  from  paraly- 
sis of  the  heart. 

Objective  Symptoms. — The  physical  examination  of  the 
abdomen  occasionally  reveals  on  inspection  a  bloated  con- 
dition and  some  spots  tender  to  pressure.  As  a  rule,  the 
lower  part  of  the  abdomen,  particularly  the  immediate 
neighborhood  of  the  navel,  is  slightly  painful  on  palpation. 
Occasionally  there  may  be  found  a  decided  tenderness, 
either  in  the  right  or  in  the  left  iliac  region.  Sometimes 
this  tenderness  may  be  quite  pronounced  in  a  line  running 
across  the  abdomen  between  the  margins  of  the  false  ribs 
(transverse  colon).  Palpation  often  elicits  gurgling  sounds 
caused  by  intestinal  coils  distended  with  gas  and  fluid  con- 
tents. This  phenomenon  is  most  frequently  observed  in 
both  iliac  regions. 

In  patients  with  thin  abdominal  walls  peristaltic  move- 
ments of  the  small  intestines  may  be  visible  either  sponta- 
neously or  after  palpatory  examination. 

The  urine  is  voided  in  small  quantities,  is  concentrated, 
and  often  shows  Rosenbach's  reaction  (Burgundy  red  color 
after  boiling  with  nitric  acid),  and  also  contains  indican 
(this  especially  if  the  process  involves  the  small  intestine). 


ACUTE  INTESTINAL  CATARRH.  89 

Casts  and  small  amounts  of  albumin  are  sometimes  found 
in  the  urine,  especially  in  severer  cases  (Fischl '). 

Feve)\ — In  the  greater  number  of  instances  there  is  no 
rise  of  temperature  during  the  course  of  this  affection.  In 
some  cases,  however,  fever  is  quite  a  prominent  symptom, 
and  the  disease  may  commence  with  violent  chills  and  a 
marked  elevation  of  temperature  (104°) .  The  temperature 
may  either  fall  suddenly  on  the  next  daj'  or  after  the  lapse 
of  a  few  days,  but  it  does  not  show  that  regular  steady  rise 
which  is  characteristic  of  typhoid  fever.  Fever  is  espe- 
cially met  with  in  those  cases  of  acute  enteritis  which  are 
caused  most  probably  by  infection  (either  pathogenic  micro- 
organisms or  tainted  food) . 

Localization  of  the  CatarrJial  Process. — In  order  to  find 
out  what  part  of  the  bowels  is  especially  affected  the  fol- 
lowing points  are  of  value : 

A  duodenitis  may  be  recognized  if  the  above  symptoms 
are  accompanied  by  icterus.  Intestinal  catarrh  attended 
with  a  constant  painful  sensation  in  the  right  epigastric 
region,  which,  besides,  is  also  tender  to  pressure,  indicates 
more  or  less  a  continuation  of  the  catarrhal  process  from 
the  stomach  to  "the  duodenujji.  Pains  appearing  in  the 
same  region  after  extensive  burns  of  the  skin  also  point  to 
a  duodenal  affection,  even  if  there  be  no  icterus. 

Jejunitis  alone  or  jejunitis  and  ileitis  without  any  affec- 
tion of  the  large  bowel  can  be  diagnosed  only  with  diffi- 
culty, for  the  principal  symptom  of  enteritis  (namely,  that  of 
diarrhoea)  is  as  a  rule  absent.  Small  amounts  of  mucus  well 
mixed  with  fecal  matter,  a  considerable  quantity  of  undi- 
gested food  particles,  and  epithelial  cells  tinged  with  yellow 
bile  pigment  in  the  faeces,  point  to  a  catarrhal  condition 
of  the  small  intestine.  Indicauuria  is  also  often  present. 
'Fischl:  Prager  Vierteljahresscbr.,  1878,  Bd.  139,  p.  27. 


90  DISEASES  OF  THE  INTESTrNIES. 

Acute  colitis  is  characterized  by  painful  sensations  and 
a  greater  tenderness  on  pressure  over  the  entire  colon. 
The  stools  are  diarrhoeal  and  contain  large  quantities  of 
mucus.  The  latter  as  well  as  the  fecal  matter  may  contain 
undecomposed  biliary  pigment.  Sigmoiditis,  described  by 
Mayor'  and  later  by  Boas"  and  Mathews/  means  an  in- 
flammatory process  involving  the  sigmoid  flexure,  and  is 
recognized  by  special  tenderness  on  palpation  of  this  por- 
tion of  the  bowel,  intense  backache,  and  a  frequent  dis- 
position to  go  to  stool. 

Proctitis,  or  inflammation  of  the  rectum,  is  characterized 
by  severe  tenesmus  and  colicky  pains  in  the  left  iliac  fossa. 
The  patients  have  a  constant  desire  to  go  to  the  closet,  but 
at  each  time  void  only  small  quantities  of  fecal  matter 
under  the  greatest  pains.  The  scybala  are  surrounded  by 
a  layer  of  mucus  which  may  be  tinged  with  blood.  Occa- 
sionally the  mucous  membrane  of  the  rectum  prolapses 
during  defecation.  It  then  appears  intensely  dark  red  and 
is  extremely  painful  to  the  touch.  Even  if  not  prolapsed, 
a  digital  rectal  examination  is  attended  with  much  pain. 
The  mucous  membrane  of  the  rectum  feels  hot  and  the  ex- 
amining finger  on  removal  soyietimes  showS  traces  of  blood. 

Duration. — The  duration  of  acute  enteritis  varies  consid- 
erably. Mild  cases  improve  in  about  two  to  five  days, 
while  those  of  a  severer  type  may  last  about  two  weeks. 
After  recovery  from  acute  enteritis  the  intestinal  tract 
remains  quite  sensitive  for  a  long  time.  If  no  attention  is 
paid  to  this  condition  and  gross  errors  of  diet  are  com- 
mitted, relapses  are  liable  to  occur.     Several  relapses  may 

'  A.  Mayor:  Revue  med.  de  la  Suisse  Romande,  1893,  No.  4. 

*  J.  Boas:  "  Krankheiten  des  Darms,  "  ii.,  p.  513. 

*  Mathews  :  "  Disease  in  the  Sigmoid  Flexure.  "  The  American  Med- 
ical Quarterly,  June,  1899. 


ACUTE  INTESTINAL  CATARRH.  91 

also  follow  each  other  and  ultimately  cause  a  chronic  en- 
teritis. 

Diagnosis. — As  a  rule  the  recognition  of  acute  enteritis 
is  very  easy.  The  characteristic  diarrhoea,  the  admixture 
of  mucus  in  the  dejecta,  the  fact  that  a  dietetic  error  has 
been  committed,  or  that  the  abdomen  (or  other  parts  of  the 
body)  has  been  exposed  to  cold,  will  all  indicate  the  nature 
of  the  affection.  The  localization  of  the  process,  whether 
affecting  more  or  less  the  entire  intestinal  tract  or  only 
certain  parts,  is  more  difficult,  and  the  important  points  of 
differentiation  have  already  been  given  above.  Frequent 
vomiting  and  very  pronounced  general  symptoms  (espe- 
cially collapse)  point  to  cholera  nostras,  which  is  the  most 
severe  form  of  acute  enteritis.  If  the  diarrhoea  is  accom- 
panied by  high  fever,  urinary  casts,  and  pains  in  the  mus- 
cles and  joints,  then  the  assumption  of  an  acute  enteritis 
of  an  infectious  type  is  justified. 

Prognosis. — The  prognosis  of  acute  enteritis  is,  as  a  rule, 
good,  the  disease  tending  to  recovery  in  a  very  short  time. 
In  children,  however,  and  very  old  and  weakened  persons, 
the  course  of  the  disease  is  sometimes  not  so  favorable  and 
mav'  lead  to  collapse  and  even  to  death. 

Treatment. — In  mild  cases  of  acute  enteritis  no  medicinal 
treatment  will  be  necessary.  Abstinence  from  food  for  one 
or  two  days,  allowing  the  patient  to  take  only  weak  tea,  a 
small  quantity  of  bouillon,  and  some  boiled  water  may  suf- 
fice to  check  the  attack.  Sometimes,  however,  especially 
if  the  attack  of  enteritis  has  been  caused  by  dietetic  errors, 
and  fulness  of  the  abdomen  and  frequent  colicky  pains  in- 
dicating that  irritating  substances  are  lodged  within  the 
intestines  are  present,  a  good  old-fashioned  drastic  is  in 
place.  Thus  castor  oil — about  one  ounce — may  be  given 
or  calomel  0.6  (gr.  x.),  the  latter  being  preferable  in  cases 


92  DISEASES  OF  THE  INTESTINES. 

of  a  probably  infectious  nature.  If  there  is  no  fever  and  the 
symptoms  are  mild,  then  the  patients  may  be  up  and  about, 
although  it  is  always  advisable  for  them  to  keep  quiet  more 
or  less.  In  cases  of  a  severer  type,  and  esi^ecially  those  with 
fever,  the  patients  should  stay  in  bed  until  the  symptoms 
are  entirely  subdued.  If  the  diarrhcea  shows  no  signs  of 
abating  after  a  day  or  two,  or  if  the  symptoms  occur  so 
frequently  as  to  be  debilitating,  then  an  opiate  is  in  place. 
Tincture  of  opium,  seven  drops  every  three  hours,  or  co- 
deine, 0.02  or  0.03  (gr.  ^-|)  also  every  three  hours,  may 
be  given.  Frequently  the  combination  of  an  opiate  with 
subnitrate  of  bismuth  and  chalk  or  with  tannigen  may  be 
useful.     Thifs  I  often  prescribe  the  following  powders : 

Q  Bism.  subnitr 6.0  (3  iss.) 

Cret.  pulv 3.0  (gr.  xlv.) 

Cod.  phosph 0.1  (gr.  iss. ) 

Elseosacch.  menth.  pip 5.0  (gr.  Ixxv. ) 

Misce  f.  pulv.     Div.  in  p.  seq.  No.  x.    S.  One  powder  three  or 
four  times  a  day. 

Or— 

^  Horph.  muriat  0.1  (gr.  iss. ) 

Tannigen, 

Elseosacch.  menth.  pip aa  5.0  (gr.  Ixxv.) 

Misce  f.  p.     Div.  in  p.  seq.  No.  x.     S.  One  powder  three  times 
daily. 

Calumba,  cascarilla,  catechu,  kino,  may  also  be  employed, 
twenty  to  thirty  drops  of  the  tinctures  being  given  about 
three  times  daily.  Another  useful  remedy  is  dermatol, 
which  may  be  administered  in  doses  of  0.5  gm.  (gr.  viii.) 
three  times  daily.  In  cases  in  which  the  entire  colon 
or  its  lower  part  is  aflfected,  irrigation  of  the  bowels  with 
astringent  solutions  is  of  great  benefit.  This  may  be  done 
with  a  solution  containing  nitrate  of  silver,  0.3  (gr.  v.) 


ACUTE  INTESTINAL  CATARRH.  93 

to  1,000  (one  quart)  water,  or  tannic  acid,  2  to  5  gm. 
(30  to  80  grains)  to  1,000  water,  or  liquor  ferri  sesqui- 
chlor.  2  :  1,000.  It  is  best  to  inject  these  solutions  after 
a  previous  washing  out  of  the.  bowel  with  plain  water  or 
soon  after  a  movement.  The  astringent  solution  should 
be  allowed  to  remain  for  about  five  to  ten  minutes,  but  in 
case  the  patient  is  not  able  to  retain  it  for  even  so  short  a 
time,  fifteen  to  twenty  drops  of  tincture  of  opium  ma^-  be 
added  to  the  injection.  This,  as  a  rule,  lessens  the  irrita- 
tion of  the  rectum  and  the  patient  is  thus  able  to  hold  the 
enema  longer.  The  temperature  of  the  water  should  be 
tepid.  All  the  above-mentioned  astringent  remedies  have 
also  slight  antisei^tic  qualities.  In  cases,  however,  in 
which  the  fermentative  processes  within  the  bowels  are 
especially  pronounced,  the  following  stronger  antifermen- 
tative  substances  may  be  used  for  irrigation :  salicylic  acid, 
2:1,000  water,  or  salicylate  of  sodium,  10.0  (oiiss.): 
1,000;  boracic  acid,  5.0  :  1,000;  creolin,  1.0  (gr.  xv.)  : 
1,000.- 

If  pains  are  present  a  warm  poultice  or  a  hot-water  bag 
over  the  abdomen  is  very  beneficial. 

Cold  drinks  should  be  forbidden.  Warm  teas,  fennel  or 
camomile,  are  useful ;  on  the  second  or  third  day  the  pa- 
tient can  be  nourished  with  soups  or  gruels  (barley,  rice, 
oatmeal  soup  cooked  with  or  without  milk) ;  water  soup 
(stale  bread  softened  in  hot  water  with  the  addition  of  a 
little  butter  and  salt)  and  hot  spiced  claret  are  then  in 
place.  A  little  later  toasted  bread,  crackers,  soft-boiled 
eggs  may  be  added  to  the  diet ;  still  later,  scraped  meat, 
lamb  chops,  tenderloin  steak,  bread  and  butter.  As  soon 
as  the  diarrhoea  has  entirely  stopped  we  may  allow  mashed 
or  baked  potatoes  in  addition  to  the  other  articles.  For 
quite  a  while  after  an  attack  of  enteritis  the  patient  has  to 


94  DISEASES  OF  THE  INTESTINES. 

be  careful  with  vegetables  and  especially  fruits.  The  first 
he  may  begin  to  take  in  small  portions  soon  after  an  at- 
tack, while  the  latter  should  be  avoided  for  a  somewhat 
longer  time. 

In  secondary  enteritis  the  principal  primary  affection 
must  be  considered  first.  Thus  enteritis  accompanying 
malaria  will  be  best  remedied  by  quinine.  Enteritis  ac- 
companying affections  of  the  lung,  heart,  or  liver  must  be 
treated  after  due  attention  has  been  given  to  the  primary 
affection. 

CHRONIC  INTESTINAL  CATARRH. 

Synonyms. — Enteritis  chronica;  Chronic  catarrh  of  the 
bowels. 

Definition. — An  affection  characterized  by  a  chronic 
inflammation  of  the  intestinal  mucosa,  giving  rise  to  vari- 
ous disturbances  in  the  function  of  the  bowels. 

Etiology. — Chronic  intestinal  catarrh  may  arise  either 
from  a  severe  acute  enteritis  which  shows  no  tendency  to  a 
cure,  or  (most  often)  from  rei)eated  attacks  of  acute  enter- 
itis following  each  other  at  shoi*t  intervals  before  the  bow- 
els have  had  a  chance  to  recover  fully.  This  often  occurs 
in  patients  who  do  not  pay  sufficient  attention  to  their 
apparently  slight  trouble  and  disregard  the  dietetic  rules 
prescribed  by  the  physician.  The  direct  factors  causing 
chronic  enteritis  are  the  same  as  those  of  the  acute  condi- 
tion. Like  acute  enteritis,  chronic  intestinal  catarrh  may 
be  divided  into  a  primary  and  a  secondary  form,  the  pri- 
mary being  idiopathic,  while  the  secondary  appears  in 
connection  with  affections  predisposing  to  this  condition. 
Thus  diseases  of  the  lungs,  especially  tuberculosis,  affec- 
tions of  the  heart,  liver,  and  kidneys,  and  diabetes  are  often 
accompanied   by  chronic    intestinal    catarrh.      Intestinal 


CHRONIC  INTESTINAL  CATARRH.  96 

parasites,  round  worms,  tapeworms,  etc.,  are  quite  often 
the  cause  of  a  secondary  chronic  enteritis,  due  to  the  irri- 
tation of  the  intestinal  mucosa  which  they  evoke. 

Morbid  Anatomy. — The  anatomical  changes  in  chronic 
intestinal  catarrh  are  similar  to  those  of  the  acute  condition 
and  are  characterized  by  hypersemia,  swelling,  and  in- 
creased  secretion  of  the  mucous  membrane.  However, 
instead  of  the  bright  red  or  intensely  dark  red  color  seen 
in  acute  catarrh,  the  mucosa  in  the  chronic  form  presents  a 
grayish  brown-red  tint.  The  blood-vessels  are  greatly  dis- 
tended, and  often  curved  into  a  serpentine  shape.  In  cases 
of  long  duration  the  intestinal  mucosa  frequently  appears 
of  a  slate  color  intermingled  with  black  pigment  (changed 
red  blood  pigment  which  has  escaped  from  the  blood-ves- 
sels). These  black  dots  are  often  found  accumulated  at 
the  tixjs  of  the  villi  and  also  in  the  immediate  neighborhood 
of  the  lymiih  follicles  and  of  the  glands  of  Lieberkuehn. 
The  surface  of  the  mucosa  is  as  a  rule  covered  with  a 
viscid  and  transparent  mucus.  The  epithelial  cells  are 
cloudy,  in  a  condition  of  fatty  degeneration,  and  partly 
desquamated.  The  interstitial  tissue  is  infiltrated  with 
cellular  elements.  The  glands  themselves  are  of  irregular 
shape,  sometimes  elongated  and  tortuous,  occasionally 
much  smaller  than  normally.  In  cases  in  which  there  is 
an  interstitial  tissue  i)roliferation,  a  constriction  around 
the  neck  of  a  gland  arises,  As  a  consequence  there  is 
retention  of  the  glandular  secretion,  and  ultimately  a  cyst 
may  develop.  Hyperplastic  processes  around  the  inflamed 
area  very  often  lead  to  the  formation  of  polypi.  The  latter 
as  a  rule  consist  of  muscular  and  fibrous  tissues  and  con- 
tain no  glands.  Exceptionally  polypoid  excrescences  may 
ap])ear  on  the  intestinal  mucosa  (especially  in  the  colon), 
which  consist  of  a  real  proliferation  of  the  intestinal  mu- 


96  DISEASES  OP  THE  INTESTINES. 

cosa  containing  glands.  An  excellent  instance  of  this  rare 
occurrence  has  been  described  by  Woodward. ' 

In  some  of  the  most  advanced  cases,  atrophy  of  the 
mucosa  may  be  present.  As  in  the  stomach,  this  process 
may  arise  from  two  entirely  different  conditions.  In  the 
one  the  process  originates  in  the  glandular  tissue ;  the  lat- 
ter becoming  inflamed,  the  seat  of  fatty  degeneration,  and 
ultimately  atrophied.  In  the  second  group  the  process 
leading  to  atrophy  originates  from  an  interstitial  tissue 
proliferation ;  the  connective  tissue  becoming  hyperti'o- 
phied,  compresses  the  glands,  and,  gaining  the  upper 
hand,  ultimately  leads  to  their  entire  disappearance. 
These  atrophic  processes,  as  a  rule,  do  not  extend  over 
the  entire  intestine,  but  more  often  involve  certain  parts. 
Thus,  the  caecum  and  its  immediate  neighborhood  have 
often  been  found  in  this  state,  even  in  persons  who  ap- 
I)arently  during  life  had  no  intestinal  affection  (Noth- 
nagel).  Large  portions  of  the  small  and  large  intestines 
or  the  entire  intestinal  tract  are  but  rarely  found  atro- 
phied, more  often  in  children  than  in  grown-up  persons. 
Ewald "  mentions  that  he  has  observed  this  rare  condition 
in  six  autopsies  in  adults.  They  all  had  suffered  during 
life  from  pernicious  anaemia  and  gastro-intestinal  disturb- 
ances. ■ 

Both  the  hyperplastic  and  atrophic  processes,  as  a  rule, 
are  not  limited  to  the  intestinal  mucosa  alone,  but  also  in- 
volve the  neighboring  structures  (the  submucosa  and  the 
muscularis).  Thus  in  the  hyperplastic  form  the  thickness 
of  the  wall  of  the  small  intestine  may  be  increased  to  six 
times  its  normal  size,  while  the  large  bowel  may  become 

'  Woodward  :  L.  c. 

«C.  A.  Ewald.  "  Diseases  of  the  Intestines.  "  Twentieth  Century 
Practice  of  Medicine,  vol.  ix.,  p.  127. 


CHRONIC  INTESTINAL  CATARRH.  97 

three  times  as  thick  as  normally.  In  atrophy  of  the  intes- 
tine there  is  also  a  degeneration  of  the  muscles.  The  gan- 
glionic cells  of  the  Meissner  and  Auerbach  plexus  have  been 
found  in  a  state  of  fatty  degeneration,  smaller  and  lessened 
in  number  in  the  atrophic  form  ( Jiirgens  '  and  Sasaki ") . 
Whether  these  changes  in  the  nervous  tissue  are  the  cause 
or  the  result  of  this  general  intestinal  atrophy  is  as  yet  not 
known. 

Several  varieties  of  ulcerative  processes  exist  complicat- 
ing chronic  intestinal  catarrh.  Some  ulcerations  arise  in 
consequence  of  superficial  erosions  of  the  mucosa,  which 
do  not  heal.  The  defect,  once  produced,  gradually  grows 
deeper.  Several  superficial  ulcers  adjacent  to  each  other 
may  grow  larger  and  unite.  Thus  a  considerable  irregu- 
lar ulceration  develops.  The  ulcerative  process  increasing 
in  depth  may  lead  to  a  secondary  phlegmonous  inflamma- 
tion of  the  submucosa,  and  ultimately  to  perforation  of  the 
intestinal  walls.  Another  danger  lies  in  the  ulcerative 
process  involving  a  blood-vessel  which  may  cause  hemor- 
rhage. If  the  perforation  through  the  intestinal  walls  oc- 
curs rapidly,  fatal  peritonitis  results ;  but  if  the  perforative 
process  develops  slowly,  then  agglutination  takes  place 
and  a  localized  peritonitis  with  or  without  the  formation 
of  a  fecal  abscess  follows.  These  eventualities  are",  how- 
ever, rare.  Generally-  the  ulcerations  either  remain  un- 
changed (not  progressing)  for  a  long  period  of  time  or  they 
cicatrize.  In  the  latter  event  strictures  of  the  intestinal 
lumen  ma}'  occasionally  develop. 

Follicular  enteritis  is  also  occasionally  the  cause  of  the 
formation  of  an  ulcer.  The  lymph  nodules  swell  up  to  pea 
size,  soften,  and  burst.     A  small  ulcer  thus  arises.     As  a 

'Jiirgens:  Berl.  kliu.  Wocliensch..  1892,  p.  357. 

'Sasaki ;  Virch.  Arch.,  Bd.  96,  p.  287. 

7 


98  DISEASES  OP  THE  INTESTINES. 

rule,  healing  takes  place,  the  mucosa  of  the  immediate  neigh- 
borhood extending  over  and  gradually  overlapping  the  de- 
fect. Sometimes,  however,  the  ulcerative  area  is  covered 
with  a  layer  of  mucus  secreted  by  the  goblet  cells  of  the 
neighboring  glands.  From  time  to  time  the  accumulated 
mucus  is  removed  from  the  defect  and  appears  in  the  dejecta 
in  form  of  particles  resembling  sago.  Extensive  ulcerations 
are  seldom  met  with  in  chronic  enteritis.  Most  often  they 
occur  in  the  enteritis  accompanying  pulmonary  tubercu- 
losis. 

Symptomatology. — Chronic  intestinal  catarrh  may  occa- 
sionallj*  exist  without  giving  rise  to  anj'  subjective  com- 
plaints. As  a  rule,  however,  there  is  a  feeling  of  discom- 
fort and  sometimes  of  slight  pains  in  the  abdomen.  These 
abnormal  sensations  may  be  especially  marked  some  time 
after  the  ingestion  of  food  or  shortly  before  the  evacua- 
tions. In  some  cases,  again,  these  annoying  sensations 
appear  early  in  the  morning,  about  an  hour  or  two  before 
rising.  Borborygmi  often  occur;  occasionally  there  is  a 
feeling  of  tension  or  of  bloating  in  the  abdomen,  which 
may  be  relieved  by  the  passing  of  flatus.  The  latter  symj)- 
tom  may  be  so  constant  and  annoying  that  the  patient  is 
afraid  to  appear  in  society  or  may  be  hindered  in  his  voca- 
tion. An  accumulation  of  gases  in  the  intestine,  especially 
in  the  colon,  may  sometimes  exert  pressure  upon  the  dia- 
phragm and  give  rise  to  asthmatic  complaints,  palpitations 
of  the  heart  and  angina  pectoris,  congestion  of  the  head 
and  vertigo.  Belching  or  passing  of  wind  alleviates  these 
symptoms  or  entirely  removes  them. 

Colicky  pains  sometimes  appear  and  are  of  short  dura- 
tion. Severe  pains,  however,  are  almost  always  ab- 
sent. 

If  the  catarrh  has  lasted  for  some  time,  then  symptoms 


CHRONIC  INTESTINAL  CATARRH.  99 

relating  to  the  general  state  of  health  often  appear.  Thus 
the  patient  may  feel  weak,  show  a  disinclination  to  work, 
be  irritable  and  somewhat  melancholic.  Some  patients 
greatly  lose  in  flesh,  and  present  an  appearance  of  suflfer- 
iug,  have  cold  extremities  and  a  slow  pulse.  Headaches, 
nausea,  and  anorexia  are  also  often  met  with. 

Whether  these  symptoms  are  due  to  auto-intoxication  as 
some,  especially  of  the  French  writers,  assume  (Bouchard  ') 
is  very  difficult  to  state.  It  is,  however,  certain  that  this 
theory  does  not  apply  to  all  cases  of  this  kind. 

Gastric  symptoms  (nausea,  anorexia,  etc.)  are  as  a  rule 
met  with  onh*  in  cases  in  which  the  small  intestine  is 
affected.  If  the  catarrh  is  limited  to  the  large  bowel  these 
symptoms  are  usually  absent. 

Objective  Symptoms. — In  some  cases  the  abdomen  is 
bloated,  especially  shorth'  after  meals,  and  somewhat  ten- 
der to  pressure.  There  maj-  be  tenderness  all  along  the 
colon ;  occasionally  the  ascending  colon  can  be  felt  as  a 
sausage-like  body  containing  hard  masses,  which  change 
their  shape  upon  digital  pressure,  or  this  part  of  the  colon 
is  filled  with  gas  and  liquids  and  a  splashing  sound  can 
then  be  easily  evoked.  Similar  phenomena  may  be  ob- 
served also  in  the  descending  part  of  the  colon  (S  Roma- 
num)  in  the  left  iliac  fossa.  Tenderness  along  the  colon 
upon  pressure  is  often  found ;  usually  the  pains  are  felt 
just  beneath  the  area  where  the  pressure  is  exerted;  some- 
times, however,  the  pain  appears  in  a  more  remote  spot. 
Thus,  for  instance,  upon  pressing  upon  the  ascending  co- 
lon in  the  right  iliac  fossa,  pain  is  felt  across  the  abdomen 
in  a  line  lying  horizontally  at  two  fingers'  width  above 
the  navel  (transverse  colon).  Intestinal  peristalsis  may  be 
observed  in  persons  with  thin  abdominal  walls,  especially 
'  Bouchard  :  "  Le^ous  sur  les  Auto-iutoxications, "  Paris.  1887. 


100  DISEASES  OF  THE  INTESTINES. 

after  a  palpatory  examination.     All  these  signs,  however, 
are  occasionally  absent. 

In  the  symptomatology  of  the  chronic  intestinal  catarrh 
the  character  and  frequency  of  the  stools  are  of  greatest 
importance.  While  in  acute  intestinal  catarrh  diarrhoea  is 
almost  a  constant  characteristic  symptom,  there  is  much 
variation  in  the  frequency  of  the  dejecta  in  the  chronic 
form.  With  regard  to  this  point  Nothnagel  divides  cases 
of  chronic  intestinal  catarrh  into  the  four  following  groups : 

1.  Cases  characterized  by  pronounced  constipation.  An 
evacuation  appears  only  once  in  two,  three,  or  four  days ; 
sometimes  only  with  the  aid  of  cathartics.  The  fecal  mat- 
ter is  usually  hard.  As  a  cause  of  the  constipation,  Noth- 
nagel assumes  a  decreased  activity  of  the  automatic  nervous 
apparatus  of  the  intestines,  this  being  the  result  of  the  ca- 
tarrhal process. 

2.  Cases  in  which  constipation  and  diarrhoea  constantly 
alternate.  For  two  or  three  days  there  may  be  a  daily 
evacuation  of  very  hard  dejecta.  On  the  following  day 
there  may  be  four  to  six  very  thin  or  mushy  movements 
mixed  with  mucus,  accompanied  by  violent  pains,  and  then 
again  constipation  for  a  day  or  two,  etc.  Or  there  may  be 
quite  normal  evacuations  (once  daily)  for  a  few  days  in 
succession  and  then  again  four  to  seven  diarrhoeal  move- 
ments in  one  day,  and  after  this  constipation.  The  prin- 
cipal feature  of  these  cases  is  the  constipation,  but  the 
excitability  of  the  nervous  apparatus  being  quite  good, 
the  decomposed  stagnant  contents  often  cause  increased 
peristalsis  and  diarrhoea.  Sometimes  these  alternating 
periods  of  constipation  and  diarrhoea  continue  for  a  long 
time.  Thus  the  patient  may  be  constipated  for  four  or 
five  weeks,  or  even  for  a  few  months,  and  then  again  the 
diarrhoea  may  set  in,  lasting  several  weeks  or  months. 


CHRONIC  INTESTINAL  CATARRH.  101 

3.  In  a  very  limited  number  of  cases  there  is  a  daily 
evacuation,  which  is  usually  not  formed  and  mushy. 

4.  Cases  in  which  there  are  for  months  several  diarrhoeal 
evacuations  daily.  The  dejecta  as  a  rule  show  the  biliary 
reaction,  or  they  may  contain  yellow  fragments  of  mucus, 
yellow  tinged  epithelia,  and  round  cells.  In  these  cases 
the  catarrhal  process  affects  not  only  the  large  bowel  but 
also  the  small  intestine.  The  absorption  suffers  and  there 
are  more  abnormal  products  in  the  contents  (acids),  which 
give  rise  to  increased  peristalsis  in  the  small  as  well  as 
large  bowel. 

Besides  these  typical  cases  there  are  some  in  which  the 
nervous  element  plays  a  part  in  combination  with  the  ca- 
tarrhal i^rocess.  Thus  there  are  patients  who  are  molested 
with  diarrhoeal  movements  only  during  the  night  or  in  the 
early  morning  hours  (morning  diarrhoea  of  Delafield'), 
while  they  feel  well  during  the  remainder  of  the  day. 

The  quality  of  the  dejecta  in  those  cases  in  which  there 
is  constipation  is  almost  normal,  with  the  only  exception 
that  there  is  an  admixture  of  mucus.  Nothnagel  considers 
this  point  the  most  important  in  the  recognition  of  a 
catarrhal  condition  of  the  intestine.  The  mucus  may  be 
absent  in  rare  instances  in  which  the  scybala  are  small  and 
the  layer  of  mucus  within  the  intestine  is  very  tough  and 
adherent,  so  that  the  fecal  matter  cannot  carry  it  along  in 
its  passage. 

The  quantity  of  mucus  varies  greatly.  While  in  most 
cases  only  small  particles  of  mucus  are  found,  there  are 
some  in  which  a  considerable  amount  may  be  passed. 
Large  amounts  of  mucus  without  fecal  matter  are  often 
found  in  enteritis  membranacea,  less  frequently  in  chronic 
enteritis. 

»F.  Delafield  :  Medical  Record,  May  11th.  1895. 


102  DISEASES  OF  THE  INTESTINES. 

In  cases  in  which  the  dejecta  are  more  or  less  thin, 
mushy  or  watery,  the  fecal  matter  has  a  light  color,  brown- 
ish-yellow  or  grayish-yellow,  and  may  at  times  be  very 
poor  in  biliary  matters.  In  these  instances,  undigested 
food  particles  are  easily  found.  Thus  small  particles  of 
meat  or  starchy  food  may  be  discovered. 

The  microscopical  examination  of  the  dejecta  is  often 
very  useful,  for  even  in  cases  in  which  macroscopically 
nothing  abnormal  can  be  discovered,  the  microscope  may 
reveal  considerable  amounts  of  undigested  meat  fibres, 
starch  granules,  and  fat  globules.  Such  substances,  if  fre- 
quently present,  indicate  that  the  catarrhal  affection  is 
principally  within  the  small  intestine.  The  microscope 
here  further  shows  the  presence  of  epithelial  cells,  some- 
times of  a  yellow  color  and  mostly  in  a  shrivelled  condi- 
tion and  embedded  in  mucus. 

According  to  Rosenheim,'  chemical  examinations  of  the 
dejecta  have  no  practical  value  in  this  affection.  The  reac- 
tion with  regard  to  litmus  varies  greatly  and  is  dependent 
upon  the  frequency  of  the  stools  and  the  quality  of  the  in- 
gested food.  As  a  rule,  however,  an  alkaline  reaction  is 
found. 

The  degree  of  fermentative  processes  in  the  intestines 
may  be  gauged  by  the  intensity  of  the  feeling  of  tension  in 
the  abdomen,  the  frequency  of  flatus,  and  the  condition  of 
the  dejecta.  The  latter  may  present  a  very  fetid  odor  and 
a  foamy  surface.  If  the  movements  are  diarrhoeal,  a  fer- 
mentation tube  may  be  filled  with  the  licjuid  contents  and 
kept  at  blood  temperature  for  a  few  hours ;  the  amount  of 
gas  developed  in  the  tube  will  indicate  the  degreie  of  fer- 
mentation.    The  character  of  the  urine  is  also  of  impor- 

'  Theodor  Rosenheim :  "  Pathologic  unci  Therapie  der  Krankheiten 
des  Danns,  "  Wien  und  Leipzig,  1893 


CHRONIC  INTESTINAL  CATARRH.  103 

tance  with  regard  to  this  point.  In  conditions  in  which 
there  is  considerable  fermentation  and  absorption  of  de- 
composed products  within  the  small  intestine,  it  usually 
gives  a  more  or  less  strong  indican  reaction  and  also  a 
decided  Rosenbach  reaction  (Burgundy  red  color  after 
boiKng  and  the  addition  of  nitric  acid). 

Chronic  enteritis  complicated  with  catarrhal  ulcers  mani- 
fests itself  by  more  frequent  attacks  of  diarrhoea,  admix- 
ture of  blood  or  pus  in  the  dejecta,  and  pain.  All  these 
symptoms  are  especially  apt  to  be  present  if  the  lower 
part  of  the  intestinal  tract  is  affected ;  if  the  ulcer  is  in  the 
small  intestine,  diarrhoea  is  often  absent,  nor  need  there 
be  any  signs  of  blood  or  pus  in  the  dejecta. 

Atrophic  processes  may  also  accompany  the  enteritis. 
If  these  involve  only  a  small  part  of  the  intestinal  tract,  no 
symptoms  whatever . maj^  result;  if,  however,  larger  parts 
of  the  small  intestine  are  affected,  the  absorption  of  food 
is  greatly  impaired  and  then  severe  symptoms  occur. 
Diarrhoea  without  passage  of  mucus  and  accompanied  by 
a  gradual  but  steady  loss  in  weight  is  present,  as  are  oc- 
casional symptoms  of  pernicious  anaemia.  This  condition 
is  found  much  oftcuer  in  infancy  than  in  later  life. 

Course. — As  a  rule  chronic  enteritis  is  a  very  tedious 
affection.  It  may  last  many  years,  even  until  the  end  of 
life.  The  intensity  of  the  symptoms  varies  a  great  deal, 
and  there  may  be  periods  of  apparent  perfect  euphoria. 
There  always  remains,  however,  a  decided  weakness  of  the 
intestine,  which  is  easily  upset  by  slight  errors  in  diet, 
which  in  healthy  persons  would  be  harmless. 

i>mf/»osi.s.— The  diagnosis  of  chronic  enteritis  is  made 
if  there  are  abnormal  sensations  within  the  abdomen,  ac- 
companied by  irregularity  of  the  bowels  and  the  presence 
of  mucus  in  the  stools.     Habitual  constipation  can  be  ea- 


104  DISEASES  OF  THE  INTESTINES. 

sily  differentiated  from  enteritis :  (1)  bj'  the  absence  of  mu- 
cus ;  (2)  by  the  fact  that  it  does  not  so  easily  nor  so  com- 
pletely respond  to  mild  cathartics.  Malignant  growths 
are  often  accompanied  by  enteritis,  and  thus  the  symp- 
toms of  the  latter  often  give  rise  to  mistakes.  A  longer 
I)eriod  of  observation,  however,  will  aid  in  arriving  at  a 
correct  diagnosis.  In  case  of  a  neoplasm  symjitoms  of 
cachexia  will  not  fail  to  appear  nor  will  the  accompanying 
enteritis  be  so  readily  alleviated  as  if  it  were  the  only 
affection.  In  ulcer  of  the  intestine  pains  predominate  and 
are  a  marked  feature.  Constipation  and  diarrhoea  depend- 
ent upon  disease  of  the  stomach  will  be  recognized :  (1)  by 
the  absence  of  mucus  in  the  stools ;  and  (2)  by  an  examina- 
tion of  the  gastric  contents.  They  will  readily  yield  to 
treatment  directed  toward  the  gastric  disorder. 

With  regard  to  the  localization  of  the  process,  the  fol- 
lowing is  of  importance:  Chronic  inflammation  confined 
to  the  small  intestine  is  usually  accompanied  by  gastric 
symptoms,  constipation,  and  the  presence  of  small  parti- 
cles of  mucus  in  the  stools,  having  a  yellow  tinge  and  being 
well  mixed  with  the  dejecta.  If  the  large  bowel  alone  is 
involved  (colitis),  there  is  constii)ation  with  the  presence  of 
more  or  less  mucus  of  a  grayish  color,  either  covering  the 
entire  fecal  mass  or  appearing  here  and  there  on  its  sur- 
face. Occasionally,  especially  if  the  lower  part  of  the 
bowel  is  affected,  the  mucus  appears  at  the  end  of  tlie  de- 
fecation and  is  then  voided  without  any  admixture  of  fecal 
matter.  If  the  inflammatory  process  involves  both  the 
small  and  the  large  intestines,  constant  diurrhcea  is  a  pre- 
dominant feature.  The  mucus  found  in  the  dejecta  has  a 
yellowish  color;  besides  considerable  quantities  of  undi- 
gested food  are  discovered  in  the  fecal  matter. 

Prognosis. — The  prognosis  of  chronic  enteritis  depends 


CHRONIC  INTESTINAL  CATARRH.  106 

upon  the  intensity  of  the  symptoms,  the  duration  of  the 
disease,  and  also. greatly  upon  the  age  and  the  constitution 
of  the  patient.  In  infancy  and  in  old  age  chronic  catarrh 
of  the  intestines  must  be  considered  a  grave  affection. 
The  same  applies  to  persons  with  a  weakened  constitution 
(tuberculosis,  cardiac  or  other  important  lesions).  A 
chronic  enteritis  of  intense  type  which  has  lasted  a  long 
period  of  time  is  hardly  ever  cured  perfectly.  There  may 
be  improvements  in  the  condition  of  the  patient,  but  re- 
lapses are  sure  to  follow  soon.  Cases  of  a  mild  nature,  how- 
ever, often  end  in  recovery,  especially  under  an  appropriate 
treatment.  In  old  age  a  complete  cure  rarely  takes  place. 
If  atrophy  of  the  intestines  has  developed,  then  the  condi- 
tion is  very  unfavorable,  the  patient  succumbing  after  a 
period  of  about  twelve  to  eighteen  months. 

Treatment. — As  in  the  treatment  of  chronic  gastric  ca- 
tarrh, and  perhaps  in  a  still  greater  degree,  hygienic  and 
dietetic  measures  here  play  the  chief  part.  It  will  be  at 
first  important  to  regulate  the  mode  of  living  of  the  patient 
— not  too  much  work,  not  too  great  business  strain,  plenty 
of  outdoor  life  and  exercise,  regularity  of  meals.  Expo- 
sure to  cold  should  be  carefully  avoided.  The  patient 
should  dress  warmly,  especially  the  abdomen  and  feet  (flan- 
nel bandage  around  the  abdomen),  and  should  be  particu- 
larly careful  not  to  get  his  feet  wet.  In  rainy  weather  shoes 
with  thick  soles  or  rubbers  should  be  worn.  With  regard  to 
diet  the  following  rules  are  of  value :  the  meals  should  be 
taken  frequently  and  in  small  portions.  Indigestible  sub- 
stances should  be  avoided.  Sufficient  nourishment  should 
be  given,  and  care  taken  that  there  is  an  increase  rather 
than  a  decrease  in  weight.  In  cases  of  diarrhoea  the  fol- 
lowing should  be  forbidden :  acid  or  sweet  wines,  all  mine- 
ral waters  charged  with  carbonic-acid  gas,  lemonade,  all 


106  DISEASES  OF  THE  INTESTINES. 

kinds  of  fruits,  salads,  all  kinds  of  cabbage  including  cauli- 
flower, rye  bread,  and  pastries.  Give  eggs  (soft-boiled 
or  scrambled),  light  meats,  especially  sweetbread,  calf's 
brain,  spring  chicken,  steak,  lamb  chops,  oysters,  lean  fish, 
white  bread  well  baked  or  toasted,  fresh  butter,  cream 
soups,  bouillon,  rice,  sago,  macaroni,  mashed  or  baked 
potatoes,  milk,  cacao,  tea.  Kumyss,  matzoon,  ginger  ale, 
good  claret  or  Tokay  may  also  be  allowed.  As  a  rule  noth- 
ing should  be  taken  in  large  portions,  and  the  drinks  should 
be  warm  or  cool  (temperature  of  the  room),  but  not  cold. 
Large  amounts  of  liquids  should  be  avoided.  Patient  with 
very  severe  symptoms  (frequent  diarrhoea,  intense  pains, 
great  weakness)  must  be  kept  abed  for  a  short  time  and 
put  on  a  rigorous  diet  at  first,  as  in  cases  of  acute  ente- 
ritis. Upon  improvement  of  the  condition  the  dietetic 
rules  described  above  should  be  followed. 

In  cases  attended  with  constipation  the  diet  may  be  more 
liberal.  Besides  all  the  articles  of  food  mentioned  in  the 
diarrhceal  group,  light  fruits,  as  oranges,  grapes,  ripe 
pears,  and  green  vegetables,  green  peas,  cauliflower  may 
be  added.  The  ingestion  of  large  amounts  of  starchy 
foods,  easily  assimilated  fats,  butter,  cream,  and  of  fluids 
is  very  beneficial.  The  more  indigestible  articles  of  food, 
like  bran  breads  (pumpernickel),  sausages,  lobster  salad, 
mayonnaise  dressings,  cabbage,  cucumbers,  etc.,  should 
be  avoided.  Beer,  ale,  Bhine  wine  taken  moderately  are 
jHirmissible. 

Hydrotherapeutic  Measures.  — In  cases  of  diarrhoea  warm 
mineral  baths  or  baths  with  the  addition  of  pine  needle 
extract  and  mud  and  bran  baths  are  favorable.  Cold  baths 
should  be  avoided.  A  cold  sponge  bath,  however,  or  a 
cold  shower  on  the  back  may  be  serviceable  in  chronic  en- 
teritis with  nervous  symptoms.     A  Priessnitz   (wet  pack) 


CHRONIC  INTESTINAL  CATARRH.  107 

over  the  abdomen  may  be  advantageously  used  over  night. 
Cold  sitz  baths  and  cold  showers  over  the  abdomen  are 
also  often  beneficial. 

Mineral  Waters. — According  to  Nothnagel  chronic  enteri- 
tis is  sometimes  greatly  improved,  and  even  perfectly  cured, 
by  a  methodical  course  of  drinking  certain  mineral  waters. 
Such  a  cure  can  best  be  carried  out  at  the  mineral  springs 
themselves.  For  here  the  patients  not  only  take  the  waters 
in  the  right  way,  but  also  observe  the  necessary  rules  of 
diet  and  are  besides  kept  free  from  their  business  cares. 
Carlsbad  is  to  be  regarded  as  the  best  place  in  cases  of 
chronic  enteritis  in  which  the  diarrhoea  is  a  prominent  fea- 
ture; Vichy  comes  next.  For  cases  of  chronic  enteritis 
with  constipation  Marienbad  seems  to  be  very  useful ;  the 
same  applies  to  Saratoga  (Hawthorn  and  Congress 
Springs).  "For  cases  in  which  neither  constipation  nor 
diarrhoea  plays  a  prominent  part  Kissingen  or  Homburg 
may  be  recommended.  Chronic  enteritis  accompanied  by 
anaemia  may  be  benefited  at  the  watering-places  of  Fran- 
zensbad  and  Elster.  The  Carlsbad  water  should  be  taken 
in  small  quantities,  about  a  wiueglassful  twice  daily ;  in 
some  cases  even  smaller  amounts  (25  to  50  gm.)  three 
to  five  times  daih*.  In  cases  which  have  been  benefited 
by  a  drinking  cure  in  Carlsbad,  Nothnagel  suggests  having 
these  patients  use  at  home  the  Carlsbad  waters  in  a  similar 
manner  as  at  this  resort,  four  times  a  year  for  an  entire 
month.  Nothnagel  says :  "  The  chronic  condition  requires 
a  chronic  treatment." 

Medicaments. — Strong  cathartics  should  be  avoided  in 
the  treatment  of  the  constipation.  Here  some  articles  of 
diet  which  moderately  increase  the  intestinal  peristalsis 
may  be  first  tried — buttermilk,  a  glass  of  cold  water, 
stewed  fruits,  and  the  like.     If  these  fail,  small  amounts 


108  DISEASES  OF  THE  INTESTINES. 

of  rhubarb,  fluid  extract  of  cascara  sagrada,  podophyllin 
may  be  used.  Of  greater  value,  however,  are  rectal  injec- 
tions either  of  plain  water  or  with  the  addition  of  some 
soap  or  salt  (a  teaspoonful  to  a  quart)  or  Carlsbad  water. 
Enemas  of  olive  oil,  as  first  recommended  by  Habershon 
and  later  by  Kussmaul  and  Fleiner,  may  also  be  advan- 
tageously used.  The  oil  enemas  should,  however,  be 
given  in  small  quantities  (half  a  pint  to  a  pint)  and  be  re- 
tained over  night  in  the  bowels.  The  frequent  use  of  calo- 
mel, castor  oil,  and  jalap  should  be  forbidden. 

The  diarrhoea  is  best  treated  either  by  large  doses  of 
subnitrate  of  bismuth  or  salicylate  of  bismuth  (1  to  2  gm., 
gr.  xv.-xxx.)  three  times  daily,  or  some  of  the  drugs  con- 
taining tannic  acid  as  their  principal  ingredient  (calumba, 
cascarilla,  rhattania,  catechu,  kino,  lig.  campechianum, 
fructus  myrtili).  Weber  '  recommends  the  following  pre- 
scription : 

Td^  Extr.  monesise, 

Extr.  calumbse aa  15.0  (  §ss.) 

Extr.  gent,  et  pulv.  liq q.s. 

Ut  f.  pil.  cxx.    S.  Three  times  daily  two  to  four  pills. 

I  very  frequently  give  fluid  extract  of  condurango  and 
fluid  extract  of  calumba  of  each  twenty  droi)s  three  times 
daily.  Dermatol  (subgallate  of  bismuth)  seems  to  be 
quite  beneficial  in  cases  in  which  the  formation  of  gas  is 
a  predominant  feature.  It  may  be  given  in  doses  of  half  a 
gram  (gr.  viii.)  three  times  daily.  For  the  same  condition 
salicylate  of  bismuth,  benzouaphthol,  and  creosote  in  small 
doses  may  be  given.  Tannigen  and  tanalbin  may  be  used 
in  doses  of  0.5  to  1  gm.  (gr.  viii.-xvi.)  three  times  daily, 
the  first  being  preferable.  Both  substances  seem  to  less- 
en fermentation,  and  by  their  astringent  qualities  exert  a 
'  L.  Weber  :  New-Yorker  medicinische  Monatsschrift,  1892. 


CHRONIC  INTESTINAL  CATARRH.  109 

beneficial  influence  upon  the  healing-process.     They  may 
therefore  be  given  continuously  for  a  long  period  of  time. 

Cases  accompanied  by  pains  will  require  an  opiate  (mor- 
phine, or  still  better  codeine),  with  or  without  the  addition 
of  belladonna  extract.  In  chronic  proctitis  suppositories 
of  opium  and  belladonna  extract  with  cacao  butter  are  indi- 
cated. Small  enemas  of  starch  solution  with  an  opiate  are 
also  useful  here.  It  is  of  course  to  be  understood  that  the 
administration  of  opiates  will  have  to  be  limited  to  a  short 
period  of  time. 


CHAPTER  IV. 

DYSENTEEY. 

Synonyms. — Enteritis  crouposa  et  necrotica;  Amoebic 
dysentery. 

Definition. — An  infectious  disease  characterized  by  spe- 
cific ulcerations  of  the  large  intestine,  gi\dng  rise  to  fre- 
quent bloody,  mucous,  or  purulent  dejections  accompanied 
by  tenesmus  aad  general  symptoms. 

Etiology. — Dysentery  occurs  under  three  different  condi- 
tions :  (1)  As  a  disease  principally  during  the  warm  season 
in  temperate  climates,  appearing  in  local  epidemics;  (2) 
endemic  in  hot  climates ;  (3)  epidemic  at  certain  times  in 
all  latitudes,  being  quickly  disseminated,  and  also  sporadic. 
While  the  endemic  zone  of  dysentery  is  limited  to  places 
lying  south  of  the  fortieth  degree  of  latitude,  epidemics  of 
the  disease  have  occurred  in  almost  every  part  of  the 
globe.  Dysentery  is  one  of  the  oldest  diseases  known. '  It 
was  observed  by  Hippocrates  and  well  described  by  Are- 
taeus  and  Celsus.  Aretaeus  already  recognized  the  ulcera- 
tion of  the  intestines  in  dysentery-. 

Various  causes  have  been  adduced  to  explain  the  origin 
of  the  disease,  and  meteorological  influences  have  been  held 
responsible  for  its  prevalence  in  local  ejjidemics.  The 
endemic  dysentery  of  the  tropics  was  generally  ascribed  to 
the  combined  action  of  heat  and  of  the  miasm  of  swamps. 
Sudden  exposure  to  cold,  eating  of  bad  and  spoiled  food, 
and  the  use  of  stagnant  or  marshy  water  were  all  believed 


DYSENTERY.  Ill 

to  be  factors  in  producing  dysentery.  It  is  only  within 
recent  years  that  its  infectious  and  also  contagious  char- 
acter has  been  recognized.  Sodre  '  says :  "  A  careful  etio- 
logical study  shows  that  dysentery  in  whatever  latitude  it 
be  observed  is  always  due  to  the  action  of  the  same  exciting 
cause,  that  it  starts  and  is  propagated  always  under  the 
influence  of  infection  and  contagion,  and  that  it  should  be 
included  in  the  group  of  parasitic  diseases."  The  exciting 
cause  of  dysentery  often  lies  in  the  soil,  in  circumscribed 
foci  of  infection.  These  foci  are  represented  by  marshes 
and  bogs  which  receive  the  drainage  from  dung  heaps  and 
cesspools,  or  by  a  soil  impregnated  with  human  dejec- 
tions. The  contagious  character  of  dysentery  is  best  shown 
by  the  following  report  of  Dr.  Beauchef.'  This  writer 
states  that  the  French  ship  Loreit,  anchored  on  the  west 
coast  of  Africa,  was  in  the  best  possible  sanitary  condition, 
not  one  of  the  crew  being  ill.  She  was  then  ordered  to 
transport  to  Gorea  the  sailors  of  the  sloop  of  war  Eagle, 
among  whom  were  twenty-nine  dysenteric  patients.  A  few 
days  afterward,  while  on  the  high  sea,  dysentery  spread 
among  the  crew  of  the  Loreit  and  ceased  only  after  all  the 
I^atients  had  been  landed  at  Gorea. 

Among  the  causes  which  contribute  to  diffuse  the  dysen- 
teric contagion  and  to  produce  the  disease  in  an  epidemic 
form  the  following  may  be  mentioned :  Crowding  together 
of  individuals,  the  vicissitudes  of  war,  bodily  privation, 
chiefly  hunger.  These  factors  are  frequently  found  asso- 
ciated in  times  of  war  when  epidemics  of  dysentery  have 
often  appeared,  causing  great  ravages. 

Since  bacteria  have  been  found  to  play  an  important 

'  A.  Sodre  -.  "  Dysentery,  "  Twentieth  Century  Practice  of  Medicine, 
vol.  xvi.,  p.  241. 
•  Beauchef  .  Cited  after  Sodre.  loo.  cit. 


112  DISEASES  OF  THE  INTESTINES. 

part  in  the  etiology  of  infectious  diseases,  many  investi- 
gators have  tried  to  discover  the  particular  micro-organism 
producing  dysentery.  Various  bacilli  and  cocci  have  been 
described  and  he]d  responsible  as  etiological  factors,  but 
their  relative  significance  has  not  been  determined.  As 
early  as  1859,  however,  Lambl '  called  attention  to  the  pres- 
ence of  amoebsB  in  the  intestinal  contents.  He  found  them 
in  the  stools  of  a  child  suffering  from  dysentery.  Loesch," 
in  1875,  observed  amoebae  in  the  dejecta  of  a  patient  suffer- 
ing from  chronic  dysentery.  He  was  the  first  to  attribute 
the  disease  to  this  micro-organism.  He  also  succeeded 
in  experimentally  producing  a  dj'sentery-like  disease  in 
a  dog  to  which  he  had  administered  rectal  injections  of 
fecal  matter  containing  amoebse.  The  observations  of 
Loesch  have  been  confirmed  by  Koch,^  who,  while  investi- 
gating dysentery  in  Egypt,  found  in  post-mortem  examina- 
tions numerous  amoebae  in  the  intestine  at  the  base  of  the 
ulcers.  The  next  important  contribution  on  this  subject 
was  made  by  Kartulis,*  who,  while  i)ractising  in  Alex- 
andria, had  an  opportunity  to  observe  several  hundreds  of 
cases  of  dysentery.  In  more  than  five  hundred  post-mor- 
tem examinations  h©  found  the  amoebae  constantly  in  the 
faeces  and  on  the  surface  of  the  ulcers,  and  in  the  abscesses 
of  the  intestine  as  well  as  of  the  liver.  In  other  affections 
of  the  intestines  Kartulis  failed  to  detect  the  amoebae  para- 
sites. He  also  succeeded  in  cultivating  them  in  infusions 
of  sterilized  dry  straw,  and  twice  produced  dysentery  in 

'  Larabl :  "  Beobachtungen  und  Studien  aus  dem  Franz-Josef-Kinder- 
Spital,  "  1860. 

'  Loesch  :  "Massenhafte  Entwickelung  von  Atnoeben  im  Dickdarm." 
Virch.  Arch  ,  Bd.  Ixv. 

3  Koch  :  Cited  after  Sodre,  loc.  cit. 

■•Kartulis:  "Zur  Aetiologie  der  Dysenterie  in  Aegypten.  "  Virch. 
Arch.,  Bd.  105,  1886. 


DYSENTERY.  113 

cats  by  inoculation  with  these  cultures.  Kartulis,  there- 
fore, declared  the  amoebae  to  be  the  true  etiological  factor  of 
dysentery. 

Very  soon  afterward  observations  of  a  similar  character 
were  made  both  abroad  and  here.  Thus  Quincke  and 
Roos,'  Hlava,"  Massaiutin/  Nasse,*  and  others  abroad,  and 
Osier,"  Stengel,"  Musser,'  Eichberg,"  Stockton,*  Council- 
man and  Lafleur,'"  and  Harris  "  of  this  country  have  also 
described  cases  of  dysentery  with  the  presence  of  the 
amoebae  parasites. 

The  theory  of  the  amoebic  origin  of  dysentery  has  been  dis- 
puted by  some  writers,  for  the}'  have  found  this  micro-or- 
ganism in  the  faeces  in  other  intestinal  disorders  and,  in 
some  instances,  even  in  the  stools  of  healthy  persons.  Thus 
Schuberg  '*  says :  "  The  abundance  of  amoebae  in  dysentery 
is  the  effect  and  not  the  cause  of  the  disease,  the  ulcerative 
lesions  affording  this  habitual  denizen  of  the  intestines 
more  favorable  conditions  for  its  development."  The  con- 
sensus of  opinion,  however,  is  that  while  harmless  amoebsB 
may  occur  in  the  intestinal  tract,  there  exists  a  pathogenic 
variety  of  this  organism  which  is  specific  for  dysentery. 
For  this  reason  Councilman  and  Lafleur  proposed  the  name 

'  Quincke  und  Roos:  Berl.  klin.  Woclienschr. ,  1893.  ' 

-Hlava:  Centralbl.  fur  Bacteriologie,  1887. 

^  Massaiutin  ■  Ibid. 

■•Nasse  :  Deutsche  med.  TVocbenschr. .  1891. 

*  Osier  :  Bulletin  of  the  Johns  Hopkins  Hospital.  1890. 

*  Stengel :  Medical  News,  November  15th,  1890. 
'Musser:  University  Med.  Magazine,  December,  1890. 
8  Eichberg  :  Medical  News,  August  22d.  1891. 

' «  Stockton  :  International  Clinics,  1894.  i. 

'0  W.  J.  Councilman  and  H.  A.  Lafleur  :  "  Amoebic  Dysentery."  Johns 
Hopkins  Hospital  Reports,  vol.  ii.,  Nos.  7-9,  1891.  p.  395. 

"  K.  F.  Harris:  "Amoebic  Dysenteny. "     American  .Journal  of  the 
Medical  Sciences,  1898,  p.  384. 
•*  Schuberg  :  Centralbl.  fur  Bakteriologie,  1893. 
8 


114  DISEASES  OF  THE  INTESTINES. 

of  amoebae  dyseuteriae  for  this  special  variety.  The  pres- 
ence of  the  amcEbsB  in  the  contents  of  abscesses  of  the  liver, 
which  are  so  often  met  with  in  dysentery'  according  to 
Sodre,  constitutes  a  powerful  argument  in  favor  of  the 
amoebic  etiology  of  the  disease. 

It  is  generally  believed  that  the  amcebae  enter  the  system 
along  with  the  food  or  drink.  Sodre  believes  that  they  can 
be  taken  in  with  the  air.  Certain  waters,  however,  ap- 
parently constitute  the  principal  means  of  propagation  of 
these  amoebae.  Thus,  Barthelemy  '  relates  that  the  troops 
when  operating  on  the  shore  of  the  Oueme,  whose  clear  run- 
ning water  was  filtered  in  Chamberland  filters  before  being 
used,  were  in  good  health  and  free  from  dysentery ;  when, 
however,  the  army  moved  away  from  the  Oueme  in  the 
direction  of  Abomey  they  were  compelled  to  use  unfiltered 
swampy  water.  From  that  moment  dysentery  made  its 
appearance.  Fitz  and  Gerry  *  described  a  case  of  dysen- 
tery with  the  presence  of  amoebae  in  the  stools  and  found 
the  same  micro-organisms  in  a  cistern,  the  water  of  which 
the  patients  constantly  used. 

Age  does  not  seem  to  have  any  influence  upon  the  disease. 
Statistically  a  greater  number  of  cases  is  found  among 
adults,  as  these  are  more  exposed  to  the  morbific  causes. 
Both  sexes  are  equally  predispose^  to  dysentery,  and  no 
race  enjoys  immunity  from  it.  One  attack  does  not  confer 
immunity  against  others.  Persons  who  suflFer  from  want 
of  food  or  who  live  on  food  of  bad  rpiality  are  most  liable 
to  contract  the  disease.  Harris  says:  "Dysentery  is  a 
disease  pre-eminently  of  the  poor,  and  is  almost  always 
associated  with  filth,  bad  hygienic  surroundings,  and  lack 
of  proper  food."    This  statement,  however,  is  somewhat 

'  Barthelemy  :  "  Medical  Report  of  the  War  of  Dahomey  " 
*  Fitz  and  Gerry  :  Cited  after  Sodre,  loc.  cit. 


DYSENTERY.  115 

too  categorical,  and  I  fully  agree  with  Sodre,  who  remarks 
that  dysentery  is  observed  also  in  persons  of  the  wealthier 
class,  who  live  on  the  best  food  and  are  surrounded  with 
everj-  comfort.  Nevertheless,  it  must  be  admitted  that  it 
is  most  frequent  among  the  poor,  and  chiefly  among  people 
who  live  under  bad  hygienic  conditions. 

Morbid  Anatomy. — In  acute  dysentery  the  large  intestine 
is  almost  alwaj  s  found  in  a  thickened  condition.  This 
thickening  involves  all  the  intestinal  coats,  but  is  most 
marked  in  the  submucosa.  Sometimes  the  latter  layer 
alone  is  involved.  The  mucosa,  when  washed  with  water, 
presents  a  bright  red,  at  some  places  dark  red  color.  The 
folds  of  the  mucosa  are  much  more  voluminous  than  nor- 
mally, and  thus  present  considerable  prominences.  Small 
red  nodules  of  various  size  are  also  seen  scattered  over  the' 
mucous  membrane.  Besides  these  nodules  more  or  less 
numerous  ulcers  are  found.  These  vary  greatly  in  size 
(from  a  pinhead  to  two  inches  long)  and  also  in  depth, 
some  being  superficial,  others  quite  deep.  The  ulcers  are 
situated  chiefly  on  the  folds  of  the  mucosa.  Ordinarily 
they  are  oblong  and  lie  transversely  to  the  long  axis  of 
the  bowel.  Sometimes  they  are  circular,  sinuous,  or  ir- 
regular. 

Councilman  and  Lafleur  have  described  on  the  surface  of 
the  mucosa  sharply  outlined  projecting  nodular  thicken- 
ings, in  which  are  observed  cavities  filled  with  a  gelatinous 
mass  communicating  with  the  surface  of  the  mucous  mem- 
brane by  small  openings,  frequently  not  larger  than  the 
head  of  a  pin.  These  writers  have  also  pointed  out  as 
characteristic  of  the  dysenteric  ulcers  their  undermined 
edges.  The  disease  process  in  dysentery,  accortling  to 
Councilman  and  Lafleur,  is  essentially  one  of  advancing 
infiltration  and  softening  of  the  submucous  and  intermus- 


116  DISEASES  OF  THE  INTESTINES. 

cular  tissue  with  subsequent  necrosis  of  the  overlying 
tissue.  The  amoebsB  reach  the  submucosa  without  injur- 
ing the  mucous  membrane.  Here  the  essential  changes 
are  first  produced,  and  the  mucous  membrane  is  interfered 
with  later.  The  mucosa  becomes  oedematous  and  ruptures 
after  a  while,  forming  an  ulcer. 

Harris  described  two  anatomical  forms  of  ulcers  found  in 
dysentery.  In  the  first  form,  which  is  encountered  most 
frequently  and  can  be  considered  as  the  typical  intestinal 
lesion  of  the  disease,  changes  in  the  submucosa  r-iay  be 
traced  in  advance  of  the  surface  ulceration  for  quite  a  dis- 
tance, thus  undermining  the  comparatively  healthy  mucosa 
above.  In  the  second  form  the  ulcers  increase  in  size  by 
gradual  softening  and  breaking  down  at  the  surface,  never 
by  necrosis  and  sloughing  of  the  underlying  tissue. 
Ulcers  of  the  second  category  occasionally  do  not  penetrate 
deeper  than  half-way  through  the  mucosa.  Generally  they 
extend  into  the  submucosa.     They  never  contain  amoebae. 

The  lesions  described  are  usually  found  throughout  the 
entire  large  bowel,  but  as  a  rule  they  do  not  extend  beyond 
the  ileocecal  valve.  In  a  comparatively  small  number  of 
cases  the  small  intestine  is  also  involved,  principally  the 
ileum. 

In  some  instances  gangrene  of  the  intestine  is  found. 
Many  authors  even  describe  a  gangrenous  form  of  dysen- 
tery. Sodre,  however,  does  not  regard  the  gangrene  as  a 
lesion  brought  on  by  the  amcebse  dysenterise,  but  by  the 
action  of  bacteria  foreign  to  the  dysenteric  process.  Ac- 
cording to  this  author  gangrene  is  a  complication  of  dysen- 
tery, but  not  a  specific  lesion.  In  this  complicated  form, 
besides  the  ulcers  described  above,  there  exist  others  of  a 
gangrenous  character.  The  gangrenous  process  may  also 
extend  beyond  the  ulcers.     On  the  brownish-red  mucosa 


DYSENTERY.  117 

gangrenous  patches  of  a  dark  color  and  of  various  size  are 
seen.  In  this  condition  the  mucosa  may  be  detached  over 
a  considerable  area  and  eliminated  with  the  dejections. 

In  chronic  dysentery  the  intestine  is  pale  with  slate  col- 
ored spots.  Its  walls  are  thickened.  The  mucosa  presents 
a  pale  rosy  or  slate  color.  Ulcers  in  diflferent  stages  of 
development  are  encountered.  Often  the  ulcers  occur  in 
groups  separated  from  each  other  by  more  or  less  extensive 
healthy  areas  of  intestine.  Sometimes  in  certain  portions 
of  the  intestines  the  ulcers  become  confluent.  Dysenteric 
ulcers  may  be  round,  elliptical,  or  serpentine  in  form  and 
usually  have  thickened  and  callous  edges.  In  the  neighbor- 
hood of  the  ulcers,  there  is  no  hypersemia  or  oedema,  al- 
though an  increase  of  fibrous  tissue  is  noted.  Undermined 
ulcers  undergoing  a  process  of  repair  are  also  found.  The 
mucosa  glands  are  found  dilated  and  filled  with  mucus.  In 
some  places  glandular  cysts  of  considerable  size  are  encoun- 
tered, in  others  the  glands  have  almost  disapi>eared,  and 
only  traces  of  them  are  left.  The  mucosa  is  thickened  and 
filled  with  round  cells.  The  submucosa  is  likewise  thick- 
ened and  in  some  places  cedematous.  Dense  fibrous  tissue 
is  found  almost  all  over  in  this  layer,  predominating,  how- 
ever, at  the  location  of  the  cicatrices  and  of  ulcers  in  the 
process  of  repair. 

In  both  the  chronic  and  the  acute  form  of  dysentery,  but 
principally  in  the  latter,  besides  the  lesion  of  the  intes- 
tines described  above,  the  liver  is  frequently  found  dis- 
eased. In  dysentery  complicated  with  gangrene  this  organ 
is  usually  greatly  increased  in  volume,  tumefied,  soft,  and 
friable.  The  cross-section  presents  a  dark  color  inter- 
spersed with  yellowish  spots.  The  latter  are  usually  some- 
what raised  above  the  surface.  On  microscopical  examina- 
tion the  hepatic  cells  show  a  large  amount  of  fat;  liesides. 


118  DISEASES  OF  THE  INTESTINES. 

small  rouud  abscesses  are  found  around  the  capillaries, 
which  are  most  probably  due  to  emboli. 

Aside  from  these  very  small  pus  collections  of  pysemic 
origin,  other  abscesses  are  found  which  differ  from  these 
by  their  size  and  the  nature  of  their  contents.  They  are 
the  so-called  dysenteric  abscesses  of  the  liver,  and  are  most 
often  encountered  in  acute  dysentery  without  gangrene. 
The  dysenteric  abscesses  vary  greatly  in  size  from  a  few 
lines  to  several  inches.  Thej^  are  situated  chiefly  in  the 
right  lobe  of  the  liver  near  the  surface.  Often  several  are 
found  together.  The  contents  of  these  abscesses  vary 
greatly.  In  the  most  recent,  the  abscess  does  not  empty 
itself  on  section.  A  small  amount  of  glairy,  semi-trans- 
parent fluid  exudes  and  leaves  behind  an  irregular  sponge- 
like mass,  the  fluid  being  apparently  held  in  the  meshes. 
In  the  older  abscesses  the  contents  are  more  fluid,  the  latter 
having  a  greenish  opaque  color.  In  these  are  suspended 
some  solid  masses  of  tissue.  In  some  instances  the  con- 
tents are  brownish  or  streaked  with  brownish-red  from 
admixture  of  blood.  Microscopical  examination  of  the  con- 
tents of  the  abscesses  reveals  the  presence  of  a  few  pus 
cells,  a  large  quantity  of  fatty  granules,  necrotic  hepatic 
cells,  a  few  blood  corpuscles,  a  great  number  of  amoebae 
(see  Fig.  28),  and  sometimes  micrococci  and  bacilli.  Ac- 
cording to  Councilman  and  Lafleur,  there  is  no  definite 
abscess-wall,  the  liver  tissue  passes  gradually  into  the 
abscess,  and  the  contour  of  the  edge  is  very  irregular, 
sometimes  extending  into  the  liver  for  a  distance  of  several 
nodules.  The  abscess  may  penetrate  the  capsule  of  the 
liver  and  either  open  externally  or  it  may  burst  into  some 
of  the  adjacent  organs,  as,  for  instance,  the  lungs,  the 
stomach,  the  intestines,  or  the  peritoneal  cavity.  Most 
often,  however,  it  bursts  into  the  lungs. 


DYSENTERY.  119 

Symptomatology  of  Acide  Dysentery.— The  disease  may 
begin  suddenly  without  any  premonitory  symptoms,  or 
after  a  few  days  of  general  malaise,  loss  of  appetite,  and 
irregularity  of  the  bowels,  the  patient  is  attacked  with 
abdominal  colic  and  diarrhoea.  These  symptoms  are 
usually  accompanied  by  chills,  vague  pains  through  the 
body,  and  fever.  The  stools,  at  first  abundant  and  watery, 
very  soon  become  scanty,  mucous,  and  usually  contain 

^  ^    €(3    «l^ 

\f^W  ^^[^^  ^S^^' 


J^ 


Fig.  "SS.— Amoebse  from  an  Abscess  of  the  Liver.    X  750.    (Sodr^) 

blood.  Gastric  disturbances  are  present  in  almost  all 
cases:  anorexia,  nausea,  often  vomiting.  The  principal 
features  of  dysentery  are  the  characteristic  stools,  the 
abdominal  pains,  and  tenesmus. 

1.  Stools.  The  evacuations  increase  in  frequency,  oc- 
curring from  twentj'  to  twenty-seven  times  during  the 
twenty-four  hours.  The  calls  to  stool  are  usually  preceded 
by  rumbling  and  colick}^  pains,  and  are  followed  by  strain- 
ing and  tenesmus.  AVhile  during  the  first  and  perhaps  the 
second  day  of  the  disease  the  motions  are  copious,  they 
soon  become  scanty.  The  patient  is  then  able  to  expel  but 
a  small  quantity,  about  a  teaspoonful  of  mucus  mixed  with 
blood,  after  painful  efforts.  Occasionally  a  few  small 
pieces  of  fecal  matter  are  passed.  The  dejecta  occasion- 
ally change  their  character  with  regard  to  frequency  as 


120  DISEASES  OP  THE  ESTESTINES. 

well  as  ooDsistencT.  Intermissions  and  exacerbations  of 
the  diarrhcea  are  sometimes  observed  in  the  coarse  of  the 
disease.  The  mocns  in  the  stools  is  almost  always  mixed 
with  blood.  In  some  cases  the  dejecta  are  hemorrhagic, 
that  is,  consist  of  almost  pure  blood,  either  red  and  fluid 
or  dark  and  coagulated.  In  dysentery  complicated  with 
gangrene  the  stools  are  serous,  of  a  dark  reddish-brown 
color,  and  contain,  in  addition  to  finely  divided  mem- 
branous threads,  large  and  thick  masses  of  necrotic  tissue 
of  a  gray  or  black  color.  The  gangrenous  dejecta  have  an 
intensely  offensive  odor.  In  many  instances  the  stool  con- 
tains no' bile. 

Amoebse  are  almost  always  found  in  the  dysenteric  stools, 
especially  if  the  lesions  are  quite  extensive.  In  examining 
the  faeces  for  amoebee  it  is  well  to  use  some  precaution. 
If  possible  the  examination  should  be  made  immediately 
after  the  dejecta  have  been  passed.  If  this  be  impossible, 
the  stool  should  be  preserved  in  a  clean  vessel  and  kept  in 
a  warm  place  until  the  examination  is  made.  The  amoebaa 
are  from  12  to  36  /i  in  diameter,  and  when  alive  frequently 
change  their  shape  by  contracting  some  part  of  their  bodies 
in  order  to  move  about.  The  bod\-  of  these  micro-organisms 
consists  of  an  outer  clear  homogeneous  substance  or  ectosarc 
and  an  inner  highly  refractive  mass  or  endosarc.  Within 
the  latter  are  usually  found  some  bacteria,  sometimes 
changed  red  blood  corpuscles,  and  a  few  quite  lai^e 
vacuoles.  The  amoebae,  when  outside  of  the  intestinal 
tract,  die  very  quickly,  especially  if  they  are  kept  in  a  cool 
place.  When  dead,  these  organisms  generally  show  a 
round  or  almost  round  configuration. 

(2)  Abdomitvd  pain.  Abdominal  pains  exist  with  greater 
or  less  severity  in  almost  every  case.  The  pains  may  be 
experienced  continuously,  or  principally  before  an  evacu- 


DYSENTERY.  121 

ation.  Most  often  they  are  located  in  the  ombilical  region 
and  in  the  left  iliac  fossa,  bat  sometimes  they  exist  in  the 
right  iliac  fossa  and  may  then  almost  simulate  an  attack  ai 
apjiendicitis.  The  pains  may  be  so  severe  that  the  i>atient 
is  forced  to  lie  i^erfectly  still  for  fear  of  increasing  them. 
Pressure  exerted  on  the  large  intestine  as  a  role  proTokes 
more  or  less  intense  pain.  According  to  Datronlean, '  in 
some  very  grave  cases  there  is  a  total  absence  of  colic 
during  the  entire  course  of  the  disease. 

(3)  Tenesmits.  Bectal  tenesmus,  consistiujg  at  first  in 
painful  sensations  of  pressure  and  constriction  and  later  in 
an  intense  desire  to  go  to  stool,  is  encountered  very  fre- 
quently. In  grave  cases  of  dysentery  the  tenesmus  may 
exist  almost  uninterruptedly.  Off  and  on  the  jxatient  suc- 
ceeds in  exi)elling  a  small  amount  of  fecal  matter  or  slime  or 
merely  gas,  and  then  feels  relieved  for  a  short  while.  Very 
soon,  however,  the  pains  in  the  anal  region  return  with  the 
same  severity.^  When  the  tenesmus  is  very  severe  it  may 
be  accompanied  by  dysuria  or  strangury.  In  this  condi- 
tion the  patient  presents  a  pitiable  appearance.  His 
straining  is  frequently  agonizing  and  occasionally  accom- 
panied by  fainting. 

Besides  the  three  cardinal  symptoms  of  dysentery  just 
described,  other  symptoms  are  often  encountered.'  Fever 
may  l3e  present,  especially  in  the  severer  form  of  the  dis- 
ease. It  may  occur  in  the  form  of  chills,  when  the  disease 
is  first  ushered  in.  As  a  rule,  the  fever  is  not  very  high 
and  shows  an  irregular  course.  Grastric  symptoms  are 
often  present.  They  consist  in  intense  anorexia,  nausea, 
vomiting,  and  pain  in  the  epigastric  region.  The  general 
condition  is  more  or  less  affected  according  to  the  severity 

'  Dutrouleau:  "Traite  des  Maladies  des  Eoropeens  dans  lea  pays 
rbauds. "  Paris.  1868. 


122  DISEASES  OF  THE  INTESTINES. 

of  the  disease.  In  grave  cases  prostration  is  marked,  the 
skin  is  dry,  the  features  are  altered,  and  the  extremities 
sometimes  cold.  The  pulse  is  small  and  rapid.  Some- 
times cerebral  disorders,  stupor,  drowsiness,  even  delirium, 
are  encountered. 

Dutrouleau  and  others  divide  cases  of  acute  dysentery 
into  three  groups:  Cases  of  a  mild  character,  those  of 
medium  intensity,  and  those  of  a  severe  type.  In  the  mild 
form,  there  exist  only  local  symptoms  which  are  usually 
not  very  intense.  In  the  form  of  medium  intensity,  the 
local  symptoms  are  more  accentuated  and  general  symp- 
toms are  encountered.  In  the  severe  form,  there  are  fever, 
intense  pain,  very  bloody  stools,  great  prostration,  and  in- 
tolerable tenesmus. 

Symptomatology  of  Chronic  Dysentery. — Chronic  dysen- 
tery develops  either  after  several  attacks  of  the  acute  form 
or  directly  from  the  first  acute  attack,  which  after  some 
periods  of  improvement  persists  to  a  greater  or  less  extent. 
Cases  of  chronic  dysentery  are  also  divided  into  three 
categories : 

(1)  The  mild  form.  The  general  nutrition  is  not  inter- 
fered with.  The  patients  usually  complain  of  slight  con- 
stipation interrupted  by  light  attacks  of  diarrhoea.  Tenes- 
mus is  either  entirely  absent  or  present  in  a  very  slight 
degree.  Even  during  the  attacks  of  diarrhoea  the  passages 
are,  as  a  rule,  not  bloody. 

(2)  Fotyri  of  medium  intensity.  Here  slight  gastric  symj)- 
toms  are  present,  like  anorexia,  belching,  etc.  The  gen- 
eral condition  is  interfered  with  to  a  considerable  extent. 
There  are  almost  always  periods  of  intermission  and  exac- 
erbation of  the  disease.  The  patient  may  have  regular 
movements  or  be  slightly  constipated,  for  a  period  varying 
from  a  week  to  ten  days,  but  soon  diarrhoea  apijears  and  lasts 


DYSENTERY.  123 

for  four  or  five  days.  The  stools  are  then  watery,  contain 
mucus,  and  -occasionally  a  little  blood.  Slight  colicky 
paius  are  present,  as  well  as  moderate  tenesmus  and  a  sen- 
sation of  heat  or  burning  in  the  rectum. 

(3)  The  severe  form.  General  nutrition  is  greatly  im- 
paired. The  patient  becomes  emaciated,  pronounced  gas- 
tric symptoms  are  present:  anorexia,  a  bad  taste  in  the 
mouth,  often  nausea,  occasionally  vomiting.  As  a  rule, 
there  is  persistent  diarrhoea,  and  the  dejecta  present  a  mu- 
cous or  muco-sanguineous  character.  Colicky  pains  in  the 
abdomen  and  pronounced  tenesmus  are  present.  In  some 
cases,  however,  the  diarrhoea  alternates  with  short  periods 
of  constipation  lasting  two  or  three  days.  The  patient 
usually  feels  very  weak  and  is  obliged  to  stay  abed  a  great 
deal  of  the  time. 

Course. — The  course  of  acute  dysentery  is  very  indefinite. 
Sometimes  the  disease  terminates  in  recovery  in  eight  to 
fifteen  days ;  sometimes  in  one  to  three  months ;  sometimes 
again  death  occurs  a  few  days  after  the  commencement  of 
the  disease.  Again,  a  case  of  dysentery  may  at  first  be  mild, 
but  later  assume  a  dangerous  character,  and  even  terminate 
fatally.  Intermissions  and  exacerbations  are  often  encoun- 
tered in  this  disease.  When  dysentery  becomes  chronic 
its  duration  varies  greatly,  often  depending  upon  the 
severity  of  each  particular  case.  Thus,  it  may  last  five  to 
six  months  or  many  years.  Even  in  the  chronic  form 
recover^'  is  not  entirely  impossible. 

Complications. — The  course  of  the  disease  is  occasionally 
modified  by  various  complications.  Peritonitis  often  re- 
sults from  an  extension  of  the  ulcerative  process  from  the 
iutestiual  wall  to  the  i)eritoueuin.  Perforation  of  the 
intestine  may  occur  in  a  similar  way,  and  is  observed 
principally  in  gangrenous   dysentery.      Sudden  death  is 


124  DISEASES  OP  THE  INTESTINES. 

occasionally  observed  in  such  an  event.  In  acute  as  well 
as  in  chronic  dysentery  severe  hemorrhages  from  the  bowel 
may  take  place.  The  loss  of  blood  may  be  so  great  even 
as  to  cause  death.  Thrombosis  of  the  femoral  artery  as 
well  as  of  the  venous  sinuses  of  the  brain  has  been  observed 
by  Laveran  '  as  a  complication  of  dysentery.  A  patient  of 
mine  with  acute  dysentery,  apparently  on  the  road  to  im- 
provement, suddenly  one  day  developed  a  paralysis  of  the 
upper  and  lower  right  extremities.  He  later  lost  con- 
sciousnes  and  died  about  forty-eight  hours  after  the  first 
signs  of  paralysis.  Here  most  probably  thrombosis  of 
some  brain  vessels  took  place. 

The  most  frequent  complication  of  dysentery  is  abscess 
of  the  liver.  In  the  majority  of  instances  it  is  observed 
in  convalescence  from  acute  dysentery  or  during  the  evolu- 
tion of  chronic  dysentery.  The  symptoms  of  the  forma- 
tion of  an  abscess  in  the  liver  are :  fever  of  an  irregular 
character,  occasionally  chills  and  pain  in  the  hepatic  region 
which  may  radiate  to  the  right  shoulder.  The  physical 
examination  often  reveals  some  enlargement  of  the  liver. 
In  the  event  of  a  liver  abscess  opening  into  the  lungs, 
there  is  persistent  cough  and  sometimes  expectoration  of  a 
reddish-brown  fluid  containing  amcebse.  Abscess  of  the 
liver  is  more  frequently  encountered  in  tropical  regions 
than  here.  The  course  of  such  an  abscess  is  very  irregular. 
Sometimes  it  progresses  rapidly,  at  other  times  it  shows 
periods  of  intermissions  and  exacerbations.  The  large 
abscesses  of  the  liver,  if  not  operated  upon,  usually  termi- 
nate in  death.  Rarely  recovery  may  follow  the  opening  of 
the  abscess  into  a  neighboring  organ. 

'  Laveran  :  "  De  la  phlebite,  de  la  thrombose  et  des  paralysies  comme 
complications  de  la  dysenterie. "  Arcliives  de  Medecine  militaire, 
1885. 


DYSENTERY.  125 

Diagnosis. — The  diagnosis  of  acute  dysentery  is  usually 
very  easy.  The  symptoms  above  described,  being  ordi- 
narily present,  cannot  fail  to  indicate  the  disease.  The 
most  reliable  evidence  is  afforded  by  the  character  of  the 
dejecta,  the  presence  of  mucus,  an  admixture  of  blood  and 
pus  corpuscles.  Appendicitis  is  occasionally  simulated  by 
dysentery  if  the  pains  involve  i^rincipally  the  appendicular 
region.  Usually,  however,  it  will  be  found  that,  besides 
the  tenderness  over  the  apj^endix,  there  are  also  similar 
areas  of  pain  over  other  portions  of  the  large  bowel,  espe- 
cially in  the  left  iliac  fossa.  Besides,  the  character  of  the 
stool  will  help  to  reveal  the  true  condition. 

The  diagnosis  of  chronic  dysenterj'  is  usually  somewhat 
more  difficult.  Repeated  examinations  of  the  fsBces  will, 
as  a  rule,  reveal  the  presence  of  amoebae  at  one  time  or 
another  and  thus  aid  in  discovering  the  disease.  Many 
diseases  of  the  rectum,  as  for  instance  proctitis,  rectal 
polypus,  and  cancer,  often  present  symptoms  similar  to 
those  of  chronic  dysentery.  A  careful  local  examination, 
however,  will  clear  up  the  diagnosis  without  difficulty. 

Prognosis.  —  Dysentery  must  always  be  considered  a 
quite  serious  disease.  Even  the  mild  form  is  at  times 
liable  to  assume  a  dangerous  character.  On  the  whole 
dysentery  must  be  regarded  as  a  treacherous  and  insidi- 
ous malady.  In  general  it  must  be  said  that  cases  of 
sporadic  dysentery  or  of  the  epidemic  form  appearing  in 
the  cold  and  temperate  zones  take  a  much  milder  course 
and  thus  present  a  more  favorable  prognosis  than  does 
the  endemic  dysentery  of  hot  climates.  These  remarks 
apply  to  both  acute  and  chronic  dysentery. 

Treatment  of  Acute  Dysentery. — The  patient  must  be  kept 
abed  and  put  on  a  diet  consisting  of  liquid  food  (milk  and 
strained  barley  water,  bouillon,   bouillon  with  egg,  egg 


126  DISEASES  OF  THE  INTESTINES. 

water,  tea).  Ipecacuanha  has  been  found  of  great  benefit 
in  this  disease.  It  may  be  given,  according  to  Sodre,  in 
the  following  combination : 

Powdered  ipecacuanha 0.1    (gr.  ij.) 

Powdered  opium 0.03  (gr  i) 

Calomel 0.05  (gr.  |) 

In  capsules,  one  to  be  taken  every  two  hours. 

In  case  the  evacuations  contain  very  small  quantities  of 
fecal  matter,  it  is  best  to  give  a  cathartic,  as  a  large  dose 
of  castor  oil  (one  to  two  tablespoonfuls)  or  sodium  or  mag- 
nesium sulphate  one  teaspoonful  twice  during  the  day. 
The  purgative,  however,  should  be  administered  only  on 
the  first  or  second  day  of  the  disease,  and  not  be  kept  up 
for  a  long  time.  In  order  to  allay  the  pains,  hot  poultices 
are  applied  over  the  abdomen  and  opium  is  administered. 
Thus,  Dover's  powder  may  be  given  in  three-grain  doses 
every  two  or  three  hours.  This  medicament  may  also  be 
combined  with  salol,  subnitrate  of  bismuth,  tannigen, 
tannalbin,  etc.  The  tenesmus,  if  severe,  must  be  subdued 
by  suppositories  containing  opium  and  belladonna,  and  by 
washing  out  the  bowel  with  a  quart  of  water  containing  a  tea- 
spoonful  of  essence  of  peppermint,  which  can  be  done  once 
or  twice  in  twenty-four  hours.  Astringent  solutions  have 
been  recommended  as  injections  for  the  large  bowel.  They 
are  not,  however,  of  great  benefit  in  acute  dysentery. 
Besides  the  points  just  mentioned,  the  condition  of  the 
patient  must  be  carefully  watched  and  every  complication 
treated  by  itself.  The  high  fever  may  necessitate  the  use 
of  an  antipyretic ;  the  weak  action  of  the  heart  analeptic 
drugs,  etc.  As  soon  as  the  severe  symptoms  are  allayed 
and  the  patient  is  on  the  way  to  recovery  the  diet  can  be 
cautiously  increased. 

Treatment  of  Chronic  Dysentei'y. — If  the  patient  is  living 


DYSENTERY.  127 

in  an  endemic  centre  of  dysentery,  it  is  best  to  send  him  to 
another  climate.  The  hygienic  surroundings  of  the  patient 
should  be  carefully  selected.  The  food  should  be  well  pre- 
pared. The  patient  should  eat  often,  not  too  much  at  a 
time,  and  should  avoid  all  coarse  and  highly  seasoned  sub- 
stances. Tannigen  gr.  viii.  three  times  daily  or  benzo- 
naphthol  in  the  same  dose,  or  subnitrate  of  bismuth  gr. 
XXX.  t.i.d.,  can  be  advantageously  given.  Sometimes  these 
drugs  are  combined  with  codeine  or  opium.  Here  local 
remedies  play  a  prominent  part.  Loesch  was  the  first  to 
recommend  injections  into  the  bowel  of  solution  of  quinine 
(1 : 5,000) ;  tannic  acid,  nitrate  of  silver,  permanganate  of 
potassium  have  also  been  emjjloyed  in  clysters  with  good 
results.  Harris  very  recently  recommended  the  use  of  hy- 
drogen dioxide.  The  ordinary  commercial  hydrogen  diox- 
ide is  diluted  from  four  to  eight  times  with  water  and  the 
solution  injected.  About  a  quart  is  injected  twice  daily  for 
about  a  week  and  then  gradually  decreased.  Harris  has 
seen  very  good  results  from  this  mode  of  treatment.  In 
cases  in  which  there  is  an  exacerbation  of  the  disorder,  the 
same  mode  of  treatment  may  be  required  as  in  acute  dys- 
entery. 


CHAPTER  V. 

ULCEES  OF  THE  INTESTINES. 

1.  DUODENAL  ULCER. 

Synonyms. — Kouud  duodenal  ulcer;  Ulcus  duodeni  pep- 
ticum  (Leube). 

Definition. — A  defect  in  the  mucous  membrane  of  the 
duodenum. 

Etiology. — The  etiology  of  duodenal  ulcer  corresponds 
with  that  of  gastric  ulcer.  It  is  undoubtedly  caused,  as  in 
the  stomach,  by  the  action  of  the  acid  gastric  juice  upon 
the  duodenal  mucosa,  the  vitality  and  nutrition  of  which 
have  been  previously  impaired.  Such  conditions  occur  as 
a  result  of  circulatory  derangements  of  various  kinds. 
Thus,  affections  of  the  lungs  and  heart  or  of  the  liver,  an 
atheromatous  state  of  the  duodenal  artery  may  be  the 
positive  factors  in  disturbing  the  circulation  of  the  mucous 
membrane.  Burns  of  the  skin  are  an  etiological  factor 
which,  while  not  operative  in  gastric  ulcer,  is  of  great  im- 
portance in  duodenal  ulcer.  After  extensive  scaldiugs  of 
the  skin,  quite  often  one  or  several  duodenal  ulcers  ap- 
pear. According  to  Mayer '  these  ulcers  develop  from  seven 
to  fourteen  days  after  the  burn,  very  seldom  much  sooner. 
The  primary  cause  of  these  ulcers  is  not  yet  known.  The 
toxic  theory  which  is  the  most  plausible  has  been  discussed 
above. 

Duodenal  ulcer  is  much  less  fre<iuent  than  gastric  ulcer. 
'  Mayer .  Annal.  de  la  Soc.  de  Med.  d'Anvers,  1865. 


DUODENAL  ULCER.  129 

Willigk '  found  it  twice  in  sixteen  hundred  autopsies.  Ac- 
cording to  this  writer,  there  are  thirty-eight  gastric  ulcers 
to  one  duodenal  ulcer.  According  to  Starke/  however, 
the  ratio  is  twelve  to  one.  Kraus  ^  found  that  the  fre- 
quency of  duodenal  ulcers  varies  in  different  countries  in 
a  similar  manner  as  does  gastric  ulcer,  the  northwestern 
part  of  Europe  having  the  highest  percentage,  while  it  is 
but  rarely  met  with  in  the  eastern  part.  In  Kraus'  expe- 
rience duodenal  ulcer  most  frequently  occurs  in  persons 
between  thirty  and  sixty  years  of  age.  Next  in  frequency 
comes  the  very  early  age  (one  to  ten,  and  especially  in- 
fancy). This  is  another  point  of  difference  between  gas- 
tric and  duodenal  ulcers,  for  the  former  hardly  ever  occur 
in  children.  With  regard  to  the  distribution  of  duodenal 
ulcer  among  the  sexes,  Kraus  found  it  much  more  preva- 
lent among  the  male  than  among  the  female  sex,  the  rela- 
tion being  ten  to  one.  According  to  Lebert,^  however, 
the  proportion  is  only  four  to  one.  This  again  is  another 
point  of  difference  in  the  etiology  of  duodenal  and  gastric 
ulcers,  for  the  latter,  as  is  well  known,  are  much  more  fre- 
quently encountered  in  women  than  in  men  (two  to  one). 

Morbid  Anatomy. — A  duodenal  ulcer  resembles  in  most 
particulars  a  gastric  ulcer.  It  is  a  defect  of  the  mucous 
membrane  having  an  oblong  and  oval  contour  and  extend- 
ing into  the  depth  of  the  mucosa  in  form  of  a  terrace  or 
funnel.  The  ulcer  presents  an  irregular  shape  only  in 
those  instances  in  which  several  ulcers  have  coalesced,  thus 
forming  one  large  defect.  The  size  of  the  ulcer  varies 
from  that  of  a  lentil  up  to  that  of  a  dollar.     The  margins 

'  Willigk  :  Prager  Vijerteljahresschr.,  1833. 
«  Starke  :  Deutsche  Klinik,  1870. 

»J.  Kraus.  "Das  perforirende  Gescbwilr  des  Duodenum,"  Berlin. 
1865. 
*  Lebert :  "  Die  Krankheiten  des  Magens,"  1878. 
9 


130  DISEASES  OF  THE  INTESTINES. 

are  usually  smooth  and  overlapping,  the  latter  being  espe- 
cially the  case  in  chronic  affections.  The  base  of  the  ulcer 
is  formed  either  by  thin  layers  of  the  remaining  intestinal 
wall,  or,  if  perforation  has  taken  place,  by  adhesions  with 
neighboring  organs. 

Situation  of  the  Ulcer. — Ordinarily  the  ulcer  is  found  in 
the  ascending  or  the  upper  horizontal  part  of  the  duodenum, 
much  more  rarely  in  the  descending  part,  and  only  excep- 
tionally in  the  lower  horizontal  section.  As  a  rule  it  is 
situated  immediately  behind  the  pyloric  fold,  rarely  at 
some  distant  point.  If  the  ulcer  is  situated  in  the  descend- 
ing part  of  the  duodenum,  e'Specially  in  the  immediate 
neighborhood  of  the  diverticulum  Vateri,  it  may  cause 
through  cicatricial  strictures  important  complications  in- 
volving the  pancreatic  and  biliary  outlets. 

As  a  rule  there  is  one  duodenal  ulcer,  exceptionally  there 
are  two  or  four.  In  the  latter  instance  the  ulcers  may  be 
found  in  different  stages  of  development :  in  the  initial  stage, 
in  that  of  commencing  cicatrization,  or  fully  cicatrized.  The 
cicatricial  process  may  lead  to  manifold  complications.  A 
stenosis  of  the  duodenum  just  behind  the  pylorus  or  at 
some  distance  may  result,  and  create  exactly  the  same  dis- 
turbances of  the  stomach  as  are  found  in  cicatricial  stenosis 
of  the  pylorus  itself.  I  had  the  opportunity  of  observing 
two  cases  of  this  kind.  In  both  the  diagnosis  of  a  benign 
stricture  of  the  pylorus  had  been  made  and  the  patients 
subjected  to  operation.  At  the  laparotomy  the  stricture 
was  found  in  the  duodenum,  in  one  case  immediately'  behind 
the  pylorus  and  in  the  other  at  some  distance  therefrom. 

Sometimes  the  ulcer  progresses  quickly  and  leads  to  per- 
foration into  the  peritoneal  cavity.  Death  from  shock  or 
from  diffuse  peritonitis  then  occurs.  If  there  is  a  slow 
extension  of  the  ulcer,  it  often  gives  rise  to  circumscribed 


DUODENAL  ULCER.  131 

peritonitis,  usually  with  adhesions  to  neighboring  organs. 
If  the  ulcer  perforates  after  adhesions  have  been  formed, 
it  usually  leads  to  an  encapsuled  purulent  peritonitis.  The 
ulcerative  process  may  occasionally  extend  to  contiguous 
jmrts  with  the  formation  of  ulcers  in  the  liver,  gall  bladder, 
or  other  neighboring  organs.  The  development  of  a  cancer 
at  the  base  of  a  duodenal  ulcer  has  also  been  observed  by 
Eichhorst '  and  Ewald." 

Symptomatology. — Occasionally  there  may  be  no  symp- 
toms whatever  during  life  and  the  duodenal  ulcer  may  not 
be  discovered  until  at  the  autopsy.  Sometimes  there  are 
no  symptoms  at  first,  then  suddenly  the  disease  manifests 
itself  by  a  severe  and  dangerous  hemorrhage  or  by  a  fatal 
perforation.  In  the  majority  of  cases,  however,  there  are 
pronounced  manifestations  during  the  existence  of  a  duo- 
denal ulcer.  Most  frequently  pains  are  present,  usually 
to  the  right  of  the  linea  alba,  extending  up  to  the  right 
parasternal  line  in  the  region  below  the  liver.  These  jmins 
usually  appear  from  half  an  hour  to  two  or  three  hours 
after  meals ;  as  a  rule  they  do  not  radiate  to  the  back  but 
rather  somewhat  downward  in  the  abdominal  cavity .  While 
the  pyloric  region  is  often  found  slightly  painful  on  press- 
ure, there  is  no  circumscribed  area  in  the  epigastrium 
intensely  i^ainful  on  deep  palpation  as  in  ulcer  of  the 
stomach.  In  rare  instances  the  pains  are  felt  by  the  patient 
in  the  epigastric  region,  which  may  also  show  tenderness 
on  pressure.  Dyspeptic  symptoms,  as  for  instance  loss  of 
appetite,  nausea,  fulness  in  the  epigastric  region,  are  as  a 
rule  absent.  Vomiting  is  likewise  a  rare  occurrence  in 
simple  duodenal  ulcer,  which  has  not  gone  on  to  a  partial 
stenosis  of  the  intestinal  lumen. 

•  Eichhorst :  Zeitschr.  f .  klin.  Medicin,  Bd.  14,  p.  533. 
2  c_  ^.  Ewald  :  Berl.  klin.  Wochenschr. ,  1886. 


132  DISEASES  OP  THE  INTESTINES. 

Hemorrhages  as  the  consequence  of  an  erosion  of  a  more 
or  less  large  blood-vessel,  through  the  progressing  necrotic 
process,  occur  in  about  thirty  per  cent  of  duodenal  ulcers. 
The  blood  is  frequently  voided  with  the  stools  (melaena) 
which  appear  dark  red  or  tarry.  Occasionally,  however, 
there  may  be  vomiting  of  blood  (haematemesis),  in  connec- 
tion with  the  melsBna  or  without  it.  If  the  hemorrhage  is 
very  great  the  patient  may  bleed  to  death.  This,  however, 
is  rare ;  as  a  rule  the  patients  recuperate  from  the  loss  of 
blood  in  about  the  same  time  as  they  do  from  a  gastric 
hemorrhage. 

Constipation  is  often  present.  The  general  condition  of 
the  patient  is  usually  good  and  there  may  be  no  loss  in 
flesh. 

Perforation  is  quite  a  frequent  event  in  duodenal  ulcer. 
The  symptoms  will  differ  according  to  whether  perforation 
has  taken  place  before  or  after  adhesions  have  been  formed. 
In  the  former  instance  perforation  leads  to  a  general  peri- 
tonitis, ending  fatally  in  eighteen  to  thirty  hours.  Rarely 
the  course  is  more  protracted  when  the  inflammatory  proc- 
ess of  the  peritoneum  has  not  assumed  large  dimensions 
and  has  become  quickly  localized  through  the  formation  of 
adhesions  in  the  neighborhood.  The  perforation  mani- 
fests itself  by  a  sudden  appearance  of  intense  pains  in  the 
abdominal  cavity,  by  the  usual  signs  of  a  general  collapse 
(cold  extremities,  very  quick  pulse),  and  by  a  swelling  of 
the  abdomen.  The  patient  presents  an  expression  of  ex- 
treme anguish  and  maintains  a  rigid  attitude  often  with 
the  legs  flexed,  being  afraid  even  to  stir.  The  abdomen  is 
painful  to  the  slightest  touch.  Nausea  and  constant  sin- 
gultus soon  appear.  Sometimes  the  patient  is  greatly 
tormented  with  vomiting.  A  few  hours  later,  in  addition 
to  these  symptoms,  the  area  of  liver  dulness  may  be  found 


DUODENAL  ULCER.  133 

absent  in  consequence  of  the  escaped  gas  which  has  accumu- 
lated above  its  surface  and  has  pressed  it  down.  Dyspnoea 
and  coma  ultimately  set  in  and  the  patient  succumbs. 

If  perforation  has  taken  place  after  adhesions  have  been 
formed,  the  same  complications  occur  as  in  ulcer  of  the 
stomach  under  similar  conditions.  The  duodenal  ulcer 
often  heals  and  there  is  a  complete  disappearance  of  all  the 
morbid  symptoms.  Sometimes  the  cicatrix  leads  to  a  stric- 
ture of  the  duodenal  lumen  and  then  gives  rise  to  ischo- 
chymia. 

Course. — The  duodenal  ulcer  has,  as  a  rule,  a  very  pro- 
tracted course.  In  some  instances  a  perfect  cure  may  be 
established  without  any  ill  consequences.  In  the  majority, 
however,  complications  are  common.  Hemorrhages,  ob- 
struction of  the  duodenal  lumen  in  consequence  of  the 
stenosis  and  perforation  are  often  observed. 

Diagnosis. — The  diagnosis  of  a  duodenal  ulcer  can  be 
made  with  certainty  only  in  a  very  few  instances.  Most 
often  only  a  probable  diagnosis  will  be  i^ossible.  A  duo- 
denal ulcer  can  be  diagnosed  with  certainty  if  the  symp- 
toms of  ulceration  follow  within  a  short  period  after  exten- 
sive scalding  of  the  skin  has  taken  place.  The  sudden 
development  of  icterus  in  a  case  presenting  symptoms  of 
gastric  ulcer  speaks  with  a  certain  amount  of  probability 
for  a  duodenal  ulcer  if  gall  stones  can  be  excluded.  The 
points  which  indicate  a  probable  location  of  the  ulcer 
within  the  duodenum  are  the  following:  1.  The  i>ains 
usually  appear  from  half  an  hour  to  tliree  hours  after  the 
ingestion  of  food  and  are  situated  most  often  to  the  right 
of  the  linea  alba  in  the  pyloric  region.  They  never  radiate 
to  the  back.  2.  Repeated  attacks  of  melsena,  either  not  as- 
sociated with  haematemesis  or  in  which  the  latter  was  only 
slight  compared  with  the  melaena.     3.  Most  of  the  patients 


134  DISEASES  OF  THE  INTESTINES. 

are  men  presenting  a  healthy  appearance.  4.  Perforation 
is  a  frequent  occurrence  in  duodenal  ulcer,  while  it  is  very 
rare  in  the  course  of  gastric  ulcer.  If  all  these  points  are 
found  associated,  then  a  probable  diagnosis  of  duodenal 
ulcer  may  be  made,  otherwise  it  is  uncertain. 

With  regard  to  the  differential  diagnosis  between  ulcer 
of  the  stomach  and  that  of  the  duodenum,  Leube '  stated 
that  in  the  latter  the  gastric  contents  show  a  normal  degree 
of  acidity,  while  in  gastric  ulcer,  as  a  rule,  hyperchlorhy- 
dria  prevails.  This  point,  however,  is  not  of  much  value, 
for  on  the  one  hand  cases  of  gastric  ulcer  are  found  with 
a  lessened  degree  of  secretion,  and  on  the  other  hand 
duodenal  ulcer  may  be  attended  with  hyperchlorhydria. 
In  the  two  cases  of  duodenal  ulcers  mentioned  above  which 
had  been  operated  upon,  the  condition  of  the  gastric  juice  in 
one  was  normal,  while  the  other  showed  intense  hyperchlor- 
hydria. The  differential  diagnosis  between  ulcer  and  can- 
cer of  the  duodenum  is  the  same  as  that  between  ulcer  and 
cancer  of  the  stomach  or  pylorus. 

Prognosis. — The  prognosis  of  duodenal  ulcer  is  almost 
always  quite  serious,  as  complete  recovery  is  very  rare. 
Relapses  after  apparent  i:)erfect  recovery  often  occur.  The 
sequelsB  to  which  the  cicatrizing  process  may  give  rise, 
namely,  obstruction  of  the  duodenal  lumen,  must  also  be 
taken  into  consideration,  and  the  possibility  of  death  from 
perforation  should  never  be  forgotten.  Another  danger 
lies  in  the  formation  of  a  cancerous  growth  on  the  base  of 
the  ulcer. 

Treatment. — On  the  whole  the  treatment  must  be  con- 
ducted on  the  same  line  as  that  of  ulcer  of  the  stomach. 

'  Leube  ;  von  Ziemssen's  "  Handbuch  der  speciellen  Pathologic  und 
Therapie, "  Bd.  vii.,  Abth.  2.  -"Die  Krankheiten  des  Magens  und 
Darms. "  Leipzig,  1876. 


EMBOLIC   AND  THROMBOTIC   ULCERS.  136 

In  some  cases  the  advisability  of  operative  intervention 
must  be  considered.  Cases  in  which  a  duodenal  ulcer  can 
be  diagnosed  with  great  probability  and  in  which  hemor- 
rhages have  recurred  several  times  may  i)erhaps  be  sub- 
jected to  a  gastro-euterostomy  during  the  period  of  com- 
parative euphoria.  For  by  this  procedure  the  duodenum 
is  relieved  of  a  great  deal  of  irritation  caused  by  the  pas- 
sage of  the  chyme,  and  the  ulcer  is  thus  given  a  better 
chance  to  heal.  Cases  in  which  the  cicatrix  has  led  to  a 
partial  stenosis  of  the  duodenal  lumen  should  certainly  be 
operated  upon,  pyloroplasty  or  gastro-enterostomy  being 
selected. 

2.    EMBOLIC  AND  THROMBOTIC  ULCERS. 

This  group  of  ulcers  resembles  the  duodenal  ulcer  in  that 
disturbances  of  the  circulation  are  the  exciting  causes. 
These  ulcers  are  of  very  rare  occurrence.  Embolic  ulcers 
were  first  described  by  Parenski. '  They  originate  in  con- 
sequence of  emboli  which  are  carried  into  the  fine  branches 
of  the  intestinal  arteries,  either  from  some  abscess  cavity 
or  from  a  focus  of  atheroma  or  endarteritis. 

The  pathological  changes  of  the  intestine  after  such  an 
occurrence  are  slight  if  a  very  small  vessel,  a  capillary  or 
an  arteriole,  has  been  occluded.  In  case  the  embolus  is  of 
an  infectious  nature,  infiltration  and  formation  of  pus  soon 
develop,  and  the  process  may  quickly  penetrate  down  to 
the  serosa  and  infect  the  peritoneal  cavity.  It  may  also 
rapidly  reach  the  intestinal  lumen  and  thus  produce  an 
ulcer.  In  the  infectious  cases  the  fatal  issue  often  ensues 
so  quickly  that  there  is  hardly  time  for  a  complete  forma- 
tion of  the  ulcer.  In  such  instances  only  the  initial  stages 
of  the  ulcerative  process  can  be  discovered.  Fine  nodules 
'  Parenski :  Wiener  med.  Jahrbucber,  1876,  Heft  3. 


136  DISEASES  OF  THE  INTESTINES. 

will  be  noticed  in  the  intestinal  wall  originating  from  the 
submucosa  and  consisting  of  accumulations  of  round  cells 
in  the  centre  of  which  are  very  small  blood-vessels. 

The  symptoms  of  these  embolic  ulcers  are  the  same  as 
those  caused  by  other  ulcerative  processes  of  the  intestines, 
namely,  severe  pain  which  may  be  of  a  colicky  nature, 
tenderness  on  pressure  over  the  abdomen,  and  diarrhoea 
with  more  or  less  bloody  admixture.  If  these  symptoms 
are  present  and  embolic  processes  can  be  discovered  in 
other  organs,  then  the  diagnosis  of  embolic  ulcer  of  the 
intestine  is  probable. 

The  clinical  symptoms  and  the  anatomical  changes  re- 
sulting from  the  obstruction  of  a  very  small  blood-vessel  of 
the  intestines  are  comparatively  slight,  compared  to  those 
which  rapidly  appear  if  the  embolus  has  entered  the 
arteria  mesaraica  superior.  This  affection  is  extremely 
rare ;  only  nineteen  cases  have  been  described  in  literature. 
The  emboli  which  have  been  found  in  the  arteria  mesaraica 
superior  itself  or  in  its  branches  could  be  traced  to  the 
left  heart  or  to  the  aorta,  which  was  the  seat  of  excres- 
cences due  to  endocarditis  or  atheroma.  There  is  either 
a  total  obstruction  of  the  entire  mesaraic  artery  or  several 
larger  and  numerous  smaller  branches  of  this  vessel  are 
occluded.  The  changes  which  frequently  result  after  the 
embolus  has  excluded  the  organ  from  circulation  are  hem- 
orrhagic infarcts  and  necrosis  with  partial  peritonitis. 
According  to  Litten,'  after  an  occlusion  of  the  arteria 
mesaraica  superior  or  its  branches,  the  intestine  is  deprived 
of  all  arterial  blood,  there  being  no  vicarious  blood  current 
from  any  anastomoses  of  these  vessels.  The  arteria  mesa- 
raica superior,  although  it  forms  anatomical  anastomoses, 

'  Litten  :  "  Ueber  die  Folgen  des  Verschlusses  der  Arteria  mesaraica 
superior."     Virchow's  Arch.,  Bd.  63. 


EMBOLIC  AND  THROMBOTIC  ULCERS.  137 

acts  functionally  like  a  terminal  artery.  The  reason  of  this 
is  that  the  anastomosing  vessels  are  of  a  very  small  calibre 
and  pursue  a  very  long  course,  and  hence  the  mesenteric 
arteries  are  not  able  sufficiently  to  supply  with  blood  the 
region  deprived  of  its  circulation. 

The  pathological  cJianges  which  appear  after  the  occlusion 
of  this  artery  consist  of  venous  hypera^mia,  hemorrhagic 
extravasations,  oedema,  and  necrosis.  In  that  part  of  the 
mesentery  and  intestine  which  was  supplied  by  this  oc- 
cluded vessel,  the  smaller  arteries  branching  off  from  the 
latter  are  contracted  and  empty,  while  the  veins  of  the 
serosa  and  mesentery  are  overfilled  with  blood.  The 
mucous  membrane  appears  dark  red ;  the  entire  intestinal 
wall  is  oederaatous  and  swollen ;  small  hemorrhages  exist 
all  over  the  mucous  membrane  and  in  the  mesentery ;  and 
the  intestinal  canal  contains  extravasated  blood  either  fresh 
or  tarry  looking.  If  the  process  has  lasted  for  some  time, 
necrotic  changes  soon  appear  and  the  mucosa  presents  a 
dirt^'  brownish-green  appearance  and  may  be  wiped  off 
from  the  other  layers  like  a  slimy  coating.  The  serous 
layer  may  be  the  seat  of  inflammation  not  only  over  the 
involved  intestinal  segment,  but  also  over  other  still  health^' 
intestinal  coils,  the  latter  being  agglutinated  and  covered 
with  a  deposit  of  fibrin.  In  the  peritoneal  cavity  there 
may  be  a  bloody  fluid  or  a  purulent  exudation. 

The  clinical  symptoms  of  an  embolus  of  the  superior 
mesenteric  artery  have  been  best  described  by  Gerhardt ' 
and  Kussmaul.'  They  are  not  always  alike,  and  two 
groups  of  cases  may  be  easily  discerned.     In  the  one,  being 

'  Gerhardt :  "  Embolie  der  Arteriae  mesentericse. "  Warzburger  med. 
Zeitschr.,  1863,  Bd.  iv. 

»  Kussmaul ;  "  Zur  Embolie  der  Arteriae  mesentericae.  "  Wtirzburger 
med.  Zeitschr.  1864,  Bd.  v. 


138  DISEASES  OF  THE  INTESTINES. 

the  larger,  an  intestinal  hemorrhage  is  the  feature  most 
marked,  in  the  other  the  affection  presents  the  picture  of 
intestinal  occlusion  with  or  without  any  signs  of  perito- 
nitis. As  a  rule  the  disease  sets  in  suddenly  with  violent 
colicky  pains  involving  the  entire  abdomen  or  some  por- 
tion of  it,  usually  in  the  neighborhood  of  the  navel. 
Soon  the  pains  grow  diffused  and  there  is  an  extreme  ten- 
derness on  pressure  over  the  abdomen.  Sometimes  the 
pain  is  accompanied  by  vomiting ;  in  rare  instances,  how- 
ever, the  pain  may  be  entirely  absent.  Such  a  case  has 
been  mentioned  by  Nothnagel.  Intestinal  hemorrhage, 
which  is  the  chief  symptom,  soon  occurs.  As  a  rule  sev- 
eral bloody  stools  appear  in  succession,  which  have  a  dark, 
almost  black,  brown  or  tarry  appearance  and  occasionally 
a  very  fetid  odor.  The  blood  of  the  hemorrhage,  how- 
ever, is  not  always  necessarily  voided  per  rectum,  for  it 
may  remain  in  the  intestinal  canal.  The  symptoms,  how- 
ever, which  characterize  a  profuse  intestinal  hemorrhage 
(falling  of  the  body  temperature  and  collapse)  will  never 
be  missing.  In  the  second  group  of  cases  there  are  merely 
signs  of  an  acute  intestinal  occlusion ;  pains,  constipation, 
and  peritonitis  being  the  only  symptoms. 

The  diagnosis  of  this  affection  can  be  made,  according  to 
Kussmaul  and  Gerhardt,  in  cases  in  which  the  source  of 
the  embolus  can  be  determined.  An  intestinal  hemorrhage 
occurs  (for  which  no  primary  lesion  exists),  colicky  pains 
of  great  violence  and  later  a  tympanitic  swelling  of  the 
abdomen  and  exudations  make  their  appearance.  The 
diagnosis  can  be  possibly  made  only  if  all  the  just  men- 
tioned points  exist.  Otherwise,  especially  if  the  intestinal 
hemorrhage  is  missing,  the  diagnosis  cannot  be  made 
during  life. 

The  prognosis  of  this  affection  is  very  grave.     As  a  rule 


EMBOLIC  AND  THROMBOTIC  ULCERS.  139 

it  ends  fatally.  It  appears,  however,  according  to  Vir- 
chow,  that  in  rare  instances  a  recovery  is  possible  after 
long  illness,  a  collateral  circulation  having  slowly  devel- 
oped. 

With  regard  to  treatment,  there  is  no  special  indication 
for  this  affection.  The  symptoms  will  have  to  be  treated 
as  such. 

Embolus  of  the  inferior  mesaraic  artery  is  a  very  rare  oc- 
currence. Two  cases  have  been  described  by  Hegar  '  and 
Gerhardt.  The  prominent  symptoms  are  violent  colicky 
pains,  tenesmus,  and  bloody  stools.  The  mucous  mem- 
brane of  the  small  intestine  remains  normal,  while  that  of 
the  colon,  S  romanum,  and  rectum  becomes  intensely  red, 
succulent,  and  contains  effusions  of  blood  here  and  there. 
Severe  anatomical  lesions  of  the  intestines,  however,  are 
absent,  for  the  circulation  is  quite  quickly  re-established 
through  anastomosis  with  the  superior  mesenteric  artery 
and  with  the  rectal  arteries  of  the  hypogastric  vessel. 

Similar  to  the  lesions  of  the  embolic  process  of  the 
superior  mesaraic  artery  are  the  consequences  which  result 
from  a  thrombus  iviihin  the  mesenteric  veins  or  the  portal 
vein.  A  few  cases  of  this  nature  have  recently  been  ob- 
served by  Pilliet,"  Grawitz,"  and  Eisenlohr.*  The  clin- 
ical picture  of  these  cases  is  as  follows :  There  appear  sud- 
denly violent  colicky  pains  in  the  abdomen.  The  latter 
swells  up  and  grows  intensely  painful  on  pressure.  Often 
vomiting  is   present,  occasionally   haematemesis.      There 

'  Hegar  :  "  Embolie  der  Luugenarterie  und  der  Arteria  mesaraica  in- 
ferior."    Virchow's  Arch.,  Bd.  93. 

'  Pilliet :  "Thromboses  des  veines  raesaraiques.  "  Progrfis  med., 
1890.  No.  25. 

•^  Grawitz  :  "  Ein  Fall  von  Embolie  der  Arteria  mesaraica  superior.  " 
Virciiow's  Arch.,  Bd.  110. 

*  Eisenlohr  :  "  Zur  Thrombose  der  ^lesenterialvenen.  "  JahrbQcher 
der  Hamburger  Staatskrankenanstalten,  1890. 


140  DISEASES  OP  THE  INTESTINES. 

may  be  constipation  or  very  freciuent  diarrhceal  and  bloody 
movements.  Accompanying  these  symptoms  there  is  al- 
ways collapse.  The  course  is  also  a  very  rapid  one,  the 
fatal  end  appearing  after  two  or  three  days.  This  affection 
is  liable  to  occur  in  advanced  pulmonary  tuberculosis,  in 
highly  marasmic  conditions  like  the  malarial  cachexia,  then 
as  a  consequence  of  pressure  of  the  portal  vein,  in  cirrhosis 
and  cancer  of  the  liver.  All  abdominal  neoplasms  may 
likewise  produce  a  thrombotic  condition  of  the  veins  by 
pressure.  The  same  may  hapijen  in  chronic  peritonitis  by 
the  formation  of  constricting  cicatricial  tissue.  Similar 
processes  also  arise  whenever  the  intestine  experiences 
pressure  or  incarceration  at  a  circumscribed  spot.  The 
venous  circulation  becomes  obstructed  by  the  pressure, 
while  the  arterial  blood  supply  owing  to  its  elastic  walls 
remains  undisturbed.  In  consequence  of  the  lacking  out- 
flow of  the  blood,  hyperemia  appears,  then  follow  hem- 
orrhagic infarcts,  and  lastly  necrosis. 

As  the  symptoms  and  treatment  of  the  following  classes 
of  intestinal  ulcers  are  identical,  we  shall  discuss  them 
together  later  on,  after  having  first  given  the  etiological  and 
anatomical  features  of  each  separately. 

3.    AMYLOID  ULCERS. 

Amyloid  processes  within  the  intestine  were  first  de- 
scribed by  Virchow '  in  1855.  The  amyloid  changes  start 
in  the  walls  of  the  small  blood-vessels  (capillaries  and  the 
finest  arteries,  occasionally  also  the  veins). 

At  first  the  vessels  of  the  mucosa  alone  are  affected,  but 

afterward  the  process  may  extend  through  the  submucosa 

and  even  through  the  entire  intestinal  wall  down  to  the 

'  R.  Virchow:  "Ueber  den  Gang  tier  ainylolden  Degeneration." 
Virchow '8  Arch.,  Bd.  8. 


TUBERCULOUS  ULCERS.  141 

serous  layer.  The  amyloid  degeneration  may  also  involve 
the  muscularis  mucosae,  or  even  ihe  entire  muscular  layer 
of  the  intestinal  walls.  The  amyloid  degeneration  of  the 
blood-vessels  makes  them  friable,  thereby  often  leading  to 
necrotic  processes  with  the  formation  of  small  ulcers. 

Amyloid  changes  are  found  more  often  in  the  small  intes- 
tine than  in  the  large  bowel.  The  mucous  membrane  of 
the  affected  part  has  a  waxy  and  pale  appearance.  The 
villi  are  missing  here  and  there. 

The  diagnosis  can  be  jjositively  made  by  means  of  the 
characteristic  color  tests.  A  solution  of  iodine  poured  over 
the  suspected  area  gives  a  brownish-red  color  which  be- 
comes violet  or  blue  after  the  addition  of  sulphuric  acid ; 
a  solution  of  methyl  violet  produces  a  bright  pink  color. 

We  have  reason  to  suspect  amyloid  processes  mthin  the 
intestine  in  conditions  which  are  known  to  be  often  asso- 
ciated with  this  process,  as  tuberculosis,  syphilis,  leukte- 
mia.  Especially'  is  this  time  if  amyloid  degeneration  is 
detected  in  other  organs  (spleen  and  liver)  as  shown  by 
their  enlargement,  and  besides  there  are  signs  of  chronic 
diarrhoea  and  insufficient  intestinal  absorption.  There  are, 
however,  no  positive  means  of  establishing  the  diagnosis 
of  amyloid  degeneration  of  the  intestine  during  life. 

4.    TUBERCULOUS  ULCERS. 

Tnher^cidosis  of  the  intestines  is  of  very  frequent  occur- 
rence. While  it  usually  appears  in  phthisical  patients, 
there  are  also  cases  of  an  undoubted  primary  intestinal 
tuberculosis.  According  to  Frerichs,'  a  tuberculous  affec- 
tion of  the  ileum  is  found  in  eighty  per  cent  of  the  cases 
of  chronic  pulmonary  phthisis.    Bayle  in  1810  was  the  first 

•  E.  Frerichs:  "Beitrage  zur  Lebre  von  der Tuberculose.  " Marburg. 
1883. 


142  DISEASES  OP  THE  INTESTINES. 

to  observe  the  occurrence  and  frequency  of  tuberculous  ul- 
cers of  the  intestine.  The  seat  of  these  ulcers  is  princi- 
pally in  the  ileum,  especially  in  its  lower  portion.  They 
may  extend  from  this  point  downward  over  the  colon  to  the 
rectum  or  upward  over  the  entire  ileum,  jejunum,  and  even 
the  duodenum. 

The  development  of  the  ulcer  takes  place  in  the  following 
way:  In  one  of  the  solitary  follicles  a  miliary  tubercle 
forms  by  extensive  accumulation  of  cells,  the  latter  swell 
up;  after  a  time  a  caseous  degeneration  appears  in  the 
centre  and  the  swollen  follicle  bursts;  thus  a  small  pea- 
sized  ulcer  is  formed.  In  the  same  way  tuberculous  proc- 
esses may  develop  in  the  agminated  follicles  and  also  lead 
to  the  formation  of  ulcers.  But  whereas  Peyer's  patches 
are  equallj^  affected  in  their  entirety  in  typhoid  fever  and 
intestinal  catarrh,  in  tuberculosis  the  infiltrations  are  con- 
fined only  to  several  follicles  of  the  group,  while  others  be- 
longing to  the  same  patch  remain  intact. 

The  ulcar  enlarges  either  by  spreading  directly  at  the 
periphery  or  by  the  coalition  of  several  defects.  As  a  rule 
the  extension  of  ulcers  into  the  deeper  layers  proceeds  in 
a  line  transversely  to  the  intestinal  lumen  corresponding 
to  the  direction  of  the  vessels  supplying  the  bowels.  Thus 
in  the  small  intestine  the  ulcer  spreads  in  a  line  parallel 
with  the  valvulsB  conniventes,  and  thus  may  form  a  circu- 
lar defect  over  the  entire  lumen  of  the  intestine,  trans- 
versely to  its  longitudinal  axis  (the  so-called  tuberculous 
girdle  ulcer).  There  exist,  however,  ulcers  of  an  oblong 
or  entirely  irregular  shape.  With  regard  to  the  depth  of 
the  ulcer  it  usually  penetrates  to  the  muscularis  and  re- 
mains at  a  standstill  there.  Small  tuberculous  foci,  how- 
ever, are  often  met  with  within  the  latter,  usually  connected 
with  the  lacteals.     Sometimes  a  destruction  of  the  mus- 


TUBERCULOUS  ULCERS.  143 

cular  layers  is  also  present  and  the  ulcer  may  advance 
down  to  the  serosa  and  may  even  perforate  into  the  peri- 
toneal cavity. 

The  fully  developed  large  tuberculous  ulcer  has  an  irreg- 
ular shape,  and  mostly  a  bright  red  margin,  being  partly 
smooth,  partly  overlapping,  sometimes  undermined.  Ita 
base  is  pultaceous,  consisting  partly  of  decomposed  tissue, 
partly  of  swollen  remnants  of  the  mucosa.  Tuberculous  in- 
filtrations are  noticeable  here  and  there  at  the  base  as  well 
as  at  the  margin.  The  surroundings  of  the  ulcer  often 
show  catarrhal  changes.  The  serosa  over  it  is  usually  in 
a  state  of  chronic  inflammation,  being  reddened,  thick- 
ened, and  surrounded  with  fibrinous  exudations.  Some- 
times there  are  agglutinations  with  other  intestinal  coils, 
the  omentum,  or  other  immediately  adjacent  organs.  The 
frequency  of  these  peritonitic  adhesions  explains  why  per- 
forations of  tuberculous  ulcers  within  the  intestine  are 
comparatively  so  rare. 

Tuberculous  ulcers  very  rarely  show  a  tendency  to  heal, 
the  process  as  a  rule  progressing  steadily  and  leading  to 
the  formation  of  new  nodules  in  the  neighborhood  of  the 
margin.  In  very  few  instances,  however,  cicatrization  of 
the  ulcers  takes  place.  The  latter,  when  occurring  in  ul- 
cers of  girdle  shape,  may  produce  a  stenosis  of  the  intes- 
tinal lumen. 

Tuberculous  ulcers  are  very  rarely  primary,  that  is  to 
say,  developing  in  the  intestines  without  a  previous  tuber- 
culous affection  existing  in  other  organs.  In  most  instances 
they  are  secondary  and  are  met  with  in  patients  who  are 
in  a  more  or  less  advanced  stage  of  pulmonary  tuberculosis. 

The  ultimate  cause  of  tuberculous  processes  in  the  intes- 
tine is  Koch's  tubercle  bacillus.  The  latter  may  be  car- 
ried into  the  intestinal  canal  with    the   sputum   which 


144  DISEASES  OP  THE  INTESTINES. 

phthisical  patients  swallow,  or  it  may  also,  in  rare  in- 
stances, be  ingested  directly  with  the  food.  Thus,  meat 
and  milk  of  tuberculous  cows  may  cause  primary  tubercu- 
losis of  the  intestine.  This  condition  is  specially  frequent 
in  infants  on  account  of  their  being  fed  with  milk  either 
from  phthisical  nurses  or  tuberculous  cows. 

5.   SYPHILITIC  ULCERS. 

Syphilitic  ulcers  of  the  intestines  are  quite  rare.  In  the 
small  intestine  they  are  mostly  met  with  in  the  new-born. 
Here  the  ulcers  are  found  either  singly  or  in  great  num- 
bers over  the  entire  small  intestine.  They  originate  in  the 
lymphatic  apparatus  of  the  mucosa  and  submucosa,  first 
forming  gummata  within  the  intestinal  walls,  which  after- 
ward undergo  rupture.  Syphilitic  ulcers  of  the  small  in- 
testine have  also  been  observed  in  adult  life  (Klebs, '  Birch- 
Hirschfeld'). 

Of  greater  clinical  importance  are  the  acquired  syphi- 
litic ulcers  which  often  occur  principally  in  the  lower 
part  of  the  colon  and  the  rectum,  including  the  anus  (most 
frequently  the  lower  part  of  the  rectum  a  few  centimetres 
above  the  anus  is  affected).  We  may  have  primary  ulcers 
of  the  rectum  through  direct  infection  after  a  preternatural 
coitus.  These  are  observed  principally  in  men  and  are 
located  in  the  median  line  of  the  anus.  They  are  character- 
ized by  a  hard  base,  sharp  margins,  and  bacon-like  appear- 
ance. We  may  also  have  secondary  ulcers  due  to  constitu- 
tional syphilis.  Condylomata  and  gummata  may  undergo 
degenerative  changes  and  form  ulcers,  which  by  their  cica- 
trization very  often  give  rise  to  the  development  of  stric- 

*  Klebs:  "Handbuch  der  pathologischen  Anatomie,"  Berlin,  1868. 

*  Birch-Hirschfeld :  "Lehrbuch  der  pathologischen  Anatomie,  "  Leip< 
zlg.  1887. 


TOXIC  ULCERS.  146 

tures  of  the  rectum.  The  latter  variety  is  much  more  fre- 
quently found  in  women  than  in  men.  Among  two  hundred 
and  nineteen  patients  with  constricting  rectal  ulcers 
Poelchen  '  found  one  hundred  and  ninety  women.  This 
author,  however,  correctly  remarks  that  not  all  these  ulcers 
resulting  in  stricture  are  due  to  syphilis.  In  a  great  many 
instances  their  origin  is  attributable  to  a  gonorrhoeal  affec- 
tion of  the  Bartholinian  glands  which  ultimately  through 
infection  leads  to  destructive  processes  within  the  rectum. 
Some  of  these  ulcers  may  also  result  from  traumatic  causes, 
such  as  the  frequent  use  of  clysters  or  hard  fecal  matter 
irritating  the  mucous  membrane. 

6.   TOXIC  ULCERS. 

Under  the  term  toxic  ulcers  of  the  intestine  are  under- 
stood defects  which  develop  in  consequence  of  abnormal 
(toxic)  products  contained  in  the  blood.  Thus  intestinal 
ulcers  occur  in  severe  forms  of  nephritis,  especially  when 
they  are  complicated  with  ursemic  symptoms.  In  leukaemia 
and  scurvy  such  ulcers  are  also  met  with.  Intestinal  ulcers 
arising  in  cases  of  poisoning  with  mercury  likewise  belong 
to  this  group.  The  ulcerative  process  in  all  these  cases  is 
best  explained  as  due  to  necrosis  in  consequence  of  the 
altered  condition  of  the  blood. 

Symptomatology. — The  symptoms  which  accompany 
ulcers  of  the  intestines  vary  greatly.  In  the  following  we 
shall  enumerate  all  the  symptoms  which  may  be  met  with 
in  these  conditions. 

1.  Diarrhoea.  Frequent  loose  movements  are  often  pres- 
ent, especially  if  the  ulcer  is  situated  in  the  lower  part  of 
the  large  bowel.     Ulcerations    of   the   small   intestines, 

'  Poelchen :     "  Zur    Aetiologie    der    stricturirendeu     Mastdarmge- 
schwiire.  "    Virchow's  Arch.,  Bd.  127. 
10 


1^  DISEASES  OP  THE  DTTESTTHEaL 

caBcam,  and  tbe  upper  end  of  the  laige  bowel  do  not  cause 
disnlMSB^  mdeas  there  is  some  other  oomplicatiiig  affection 
(a  catarriial  condition  of  the  bowels  or  an  amvloid  state). 
Bat  evoi  if  tlie  nloer  is  situated  in  the  lower  part  of  the 
colon,  diarrlKBa.  may  be  absent  in  rare  instances. 

2.  The  occwrrenct  cf  blood  w  pus  in  the  dejeda.  Blood 
maj  be  voided  with  the  stools  in  oonseqnence  of  a  small 
henMHThaee  of  the  ulcerated  intestine.  If  there  is  no  gas- 
tric nicer,  and  odier  symptoms  {mint  toward  intestinal  ulcer, 
the  presence  of  blood  will  help  to  make  the  diagnosis  more 
probable.  Bat  it  is  by  no  means  a  positive  sign,  for,  on 
the  one  hand,  an  intestinal  nloer  may  exist  without  any 
hemorrhages,  and,  on  the  other  hand,  intestinal  hemor- 
rhages may  occur  from  other  causes  than  ulcer.  The 
presence  of  pus  in  the  stools  seems  to  have  much  greater 
importance.  According  to  Nothnagel,  real  pus  (numerous 
round  cells)  in*the  feces  is  one  of  the  most  valuable  signs 
of  ulceration  of  the  intestines.  It  is  to  be  understood  that 
pus  may  also  be  present  in  ulcerative  prooeases  accom- 
panying neoplasms  of  the  intestines  and  in  abscesses  which 
opoi  into  the  intestine.  The  latter  two  conditions  will 
have  to  be  excluded  before  we  can  infer  the  existence  of  an 
intestinal  ulcer  fn^n  this  symptom.  The  amount  of  pus 
in  irae  ulcerations  of  the  intestines  is,  as  a  rule,  very 
amall,  and  it  is  necessary  to  examine  the  dejecta  quite 
tiioroughly  in  order  to  find  it.  While  the  presence  of  pus 
ja  ao  impcRtant  a  symptom  in  intestinal  ulcer,  its  absence 
by  no  means  speaks  against  it.  For  there  may  be  no  for- 
mation of  pus  at  the  site  of  the  ulcerative  spot,  or  the  pus 
may  be  changed  to  sodi  a  degree  that  it  is  no  longer  reoog- 
niimhle,  especially  if  ihe  ulcer  is  situated  high  up  in  the 


3.  Tke  existence  of  tidferde  baciUi  in  the  dejecta  is  of 


INTESTmJLL  ULCEBS.  147 

great  impoitaiiee  in  cases  in  which  pnlmcMiaiy  tabetcn- 
losis  can  be  exclnded,  since  thej  then  show  pfrimazy  intes- 
tinal tnbercnloeis.  The  afasenoe  ci  the  tubercle  bacilli 
does  not  speak  against  the  presenoe  cl  nlceratii^  aieas  in 
the  intestines,  nor  does  their  presence  positiTelj  indicate  a 
tabercnlons  affection  of  tbe  intestine  when  pnlmonaiy  taber- 
cnlosis  exists,  for  these  microbes  aie  then  nsnallj  deiiTed 
from  the  spnta  which  have  been  swallowed  and  carried 
down  with  the  passages. 

4.  Bains.  If  pains  exist  in  the  abdomen  in  a  more  or 
less  cutcmnscribed  spot  for  a  long  period  of  time,  and 
if  these  pains  are  increased  on  pressnre,  thej  are  prob- 
ably  dne  to  an  nicer  in  the  intestines.  The  absraioa 
of  this  symptom,  however,  speaks  in  no  way  against  an 
nicer,  nor  is  its  presence  an  absolute  positiTe  symptom  for 
nicer. 

The  general  state  of  the  system  need  not  be  disturbed, 
if  the  ulcers  are  only  few  in  number  and  very  smalL  If 
their  number,  however,  is  great  and  their  size  extensive, 
so  that  a  large  part  of  the  intestinal  tract  is  involved  in  the 
ulcerative  process,  then  nutritive  distmbanees  will  manifest 
themselves  and  marked  emaciation  take  place. 

DiagnoBU. — As  may  be  seen  from  the  descriptiQn  ol  the 
symptoms,  the  diagnosis  ci  ulcer  of  the  intestines  is,  as  a 
rule,  quite  difficult.  Their  existence  may  be  suspected 
whenever  there  is  diarrhoea  of  a  severe  natore  and  more  or 
less  intense  pain  over  a  certain  fixed  region  of  the  abdomoi 
extending  over  a  great  period  of  tinie.  A  positive  diag- 
nosis can  be  made  onfy  in  the  following  instances: 

1.  If  necrotic  pieces  of  the  intestinal  mnoosa  <»  pas 
appear  in  ibe  stools  (in  the  latter  instance  the  perforation 
of  an  abscess  into  the  intestine  has  to  be  excluded). 

2.  The  more  or  less  frequent  appearance  of  small  amoonta 


148  DISEASES  OP  THE  INTESTENES. 

of  blood  quite  changed  in  the  stool,  if  ulcer  of  the  stomach 
or  vicarious  bleeding  can  be  excluded. 

3.  Diarrhoea  and  the  constant  appearance  of  tubercle 
bacilli  in  the  stools,  when  pulmonary  tuberculosis  can  be 
excluded.  This  points  to  the  presence  of  tuberculous  proc- 
esses (ulcers)  in  the  intestine. 

4.  If  the  ulcers  are  situated  in  the  lower  part  of  the  colon 
or  rectum  and  are  accessible  to  a  direct  visual  examination. 

x'he  nature  of  the  ulcers  (whether  catarrhal,  tuberculous, 
syphilitic,  or  toxic)  must  be  elucidated  by  a  thorough 
knowledge  of  the  history  of  the  case  and  the  results  of  an 
accurate  examination  of  the  patient. 

Prognosis. — The  prognosis  of  intestinal  ulcers  will  de- 
pend largely  upon  their  number,  size,  and  nature.  A  few 
small  catarrhal  ulcere  will  heal  quickly  without  any  further 
trouble.  Amyloid  ulcers  hardly  ever  show  a  tendency  to 
heal.  Tuberculous  ulcerations  occasionally  are  amenable 
to  treatment,  still  more  so  are  the  syphilitic  ulcers.  Very 
extensive  ulcerations,  no  matter  of  what  nature,  are  very 
dangerous  to  life. 

Treatment. — In  the  treatment  of  intestinal  ulcers  the 
etiological  factors  play  the  greatest  part.  Thus,  in  tu- 
berculous ulcers  general  hygienic  rules  will  have  to  be 
observed.  An  out-of-door  mode  of  living,  and,  if  pos- 
sible, in  the  mountains,  should  be  recommended.  Guai- 
acol  carbonate,  creosote,  ichthalbin  are  of  value.  In 
syphilitic  ulcers  general  anti-syphilitic  treatment  should 
be  instituted:  inunctions  with  mercury,  or  injections  of 
sublimate  or  calomel,  or  the  administration  of  large  doses 
of  potassium  iodide.  In  toxic  ulcers  (as  those  due  to 
uraemia  and  mercurial  poisoning)  the  treatment  must  be 
directed  against  the  primary  trouble.  Besides  the  etio- 
logical   therapy,   intestinal    ulcers    require    specific  and 


INTESTINAL  ULCERS.  149 

symptomatic  treatment.  The  treatment  directed  to  the 
healing  of  the  ulcers  is  very  successful  if  the  latter  are  situ- 
ated in  the  rectum  or  in  the  lower  part  of  the  colon,  while 
this  object  can  hardly  be  attained  if  they  exist  high  up  in  the 
colon  or  in  the  small  intestine.  In  the  former  instance  the 
ulcers,  if  accessible  to  view,  may  be  directly  treated  by  the 
application  of  a  strong  solution  of  nitrate  of  silver  or  pro- 
ta,rgol.  If  not  visible  but  situated  in  the  colon,  injections  of 
a  0.2  to  1  per  cent,  solution  of  nitrate  of  silver  or  of  tannic 
acid  of  the  same  strength  into  the  bowels  are  of  value.  If 
the  ulcers  are  situated  in  the  small  intestine,  large  doses 
of  subnitrateof  bismuth  (1  to  2  gm.  [gr.  xv.  to  xxx.]  three 
times  a  day)  may  be  tried.  The  symptoms  which  accom- 
pany the  ulcer  and  vary  from  time  to  time  will  have  to  be 
treated  as  such.  Diarrhoea,  hemorrhage,  and  pain  must 
be  combated  with  the  customary  remedies. 

Most  patients  should  be  kept  abed  for  some  time.  The 
application  of  a  hot-water  ba^  or  a  wet  pack  over  the 
abdomen  is  very  beneficial. 

The  diet  should  contain  nourishing  but  easily  digestible 
and  non-irritating  food.  Thus,  milk,  kumyss,  matzoon, 
eggs  beaten  up  in  milk,  soft-boiled  eggs,  farina,  oat  meal 
cooked  in  milk,  mutton  broth,  chicken  soup,  scraped  beef, 
calf's  brain,  sweetbreads,  cacao,  tea,  and  toast  may  be 
given. 


CHAPTER  VI. 

NEOPLASMS  OF  THE  INTESTINE. 

MALIGNANT  GROWTHS. 

Cancer. 

Definition. — ^An  epithelial  neoplasm  of  the  intestinal 
walls. 

Etiology. — The  etiology  of  intestinal  cancer,  like  that  of 
cancerous  disease  of  other  organs,  is  stiU  unknown.  The 
traumatic  theory  (repeated  irritation  of  one  particular 
area)  appears  quite  plausible  with  reference  to  this  organ. 
As  will  be  seen  later,  this  malady  occurs  much  more  fre- 
quently in  those  parts  of  the  bowels  in  which  the  passage 
of  fecal  matter  is  more  apt  to  be  retarded,  and  in  conse- 
quence to  cause  irritation. 

With  regard  to  sex,  it  is  generally  accepted  that  int^- 
tinal  cancer  occurs  somewhat  oftener  in  men  than  in  women. 
With  reference  to  age  it  is  chiefly  met  with  during  the 
period  from  forty  to  sixty-five  years.  Cancer  of  the  intes- 
tine is  occasionally  found  also  in  young  people,  this  hap- 
pening much  more  commonly  than  cancer  of  the  3tomach 
or  of  other  organs.  Nothnagel '  has  observed  cancer  of  the 
csBcum  in  a  twelve-year-old  boy,  and  Schoening  ^  reports 
two  cases  of  rectal  cancer  in  girls  seventeen  years  old. 

'  H.  Nothnagel :   "  Die  Erkraukungen  des  Darms  und  des  Perito- 
neum, "  Wien,  1898. 
•Schoening:  Deutsche  Zeitschr.  f.  Chirurgie,  Bd.  xxii.,  1885. 


MALIGNANT  GROWTHS.  161 

According  to  Maydl, '  the  total  number  of  intestinal  cancers 
occurring  from  the  first  to  the  thirtieth  year  amounts  to 
one-seventh  of  the  entire  number  of  cases. 

Location. — With  regard  to  location  the  frequency  of  the 
affection  in  the  different  portions  of  the  bowel  varies.  The 
fi-equency  gradually  increases  the  lower  down  the  growth 
is  situated,  beginning  with  the  jejunum  and  ending  with 
the  rectum.  Among  one  hundred  and  sixty  autopsies  on 
cases  of  cancer  of  the  different  organs,  Maydl  found  in  one 
hundred  cancerous  disease  of  the  bowels.  In  one  hundred 
and  ten  autopsies  of  patients  suffering  from  intestinal 
cancer,  Bryant ''  found  the  neoplasm  located  six  times 
within  the  small  intestine,  seven  times  in  the  csBcal  and  ileo- 
ca3cal  regions,  nineteen  times  in  the  transverse  colon,  includ- 
ing the  hepatic  and  splenic  flexures,  seventy-eight  times  in 
the  sigmoid  flexure  aud  rectum.  Maydl  gives  the  follow- 
ing locations  of  the  tumor  in  one  hundred  autopsies :  Two 
in  the  duodenum,  four  in  the  ileum  (none  in  the  jejunum), 
forty-six  in  the  large  bowel  (in  the  vermiform  process,  one; 
csecum,  nine;  ascending  colon,  six;  colon  seventeen;  sig- 
moid flexure,  thirteen),  and  forty-eight  in  the  rectum.  As 
regards  cases  observed  during  life,  Maydl  gives  the  follow- 
ing figures :  During  twelve  years  there  were  in  the  Wiener 
AUgemeines  Krankenhaus  246,827  patients.  Among  these 
there  were  6,287  patients  with  cancer.  Among  the  latter 
there  were  254  cases  of  cancer  of  the  bowels,  and  in  224  of 
these  the  neoplasm  was  in  the  rectum.  This  certainly  shows 
the  great  predilection  of  intestinal  cancer  for  the  rectum. 

Intestinal  cancers  are  almost  always  primary.  It  is 
exceptional  for  cancer  of  the  l)owels  to  develop  by  way  of 
metastasis.     It  is  obvious,  however,  that  cancer  in  this 

'  Maydl :  "  Ueber  den  Darmkrebs, "  Wien,  1883. 

'  Joseph  D.  Bryant :  Annals  of  Surgery,  February,  1893. 


162  DISEASES  OP  THE  INTESTINES. 

region  may  develop  secondarily  as  a  result  of  direct  exten- 
sion of  the  cancerous  process  from  a  contiguous  organ. 
This  often  occurs  in  cancer  of  the  stomach,  gall  bladder, 
or  pancreas.  Intestinal  cancer  often  gives  rise  to  metasta- 
ses in  other  organs.  According  to  Miiller, '  these  are  more 
fre(iuently  met  with  in  cancer  of  the  small  intestine  than 
in  that  of  the  large  bowel.  The  lymphatic  glands  are  also 
often  secondarily  affected.  Those  in  the  neighborhood  of 
the  neoplasm  show  a  greater  tendency  to  become  cancer- 
ous than  those  farther  off. 

Morbid  Anatomy. — All  varieties  of  cancer  are  found  in 
the  intestines.  Most  frecjuently,  however,  the  cylindrical 
epithelial-celled  carcinoma,  having  a  glandular  structure 
(adeno-carcinoma),  is  encountered.  The  latter  takes  its 
origin  in  the  epithelial  cells  of  the  follicles  of  Lieberkuehn. 
Colloid  carcinoma  is  quite  often  found  in  the  rectum,  while 
melano-carcinoma  is  here  quite  rare.  Occasionally  the 
pavement-celled  carcinoma  (epithelioma  cancroid)  is  met 
with,  especially  in  the  lower  part  of  the  rectum,  starting 
principally  from  the  anus.  It  often  involves  the  perineum 
and  the  vagina. 

The  neoplasm  varies  in  consistency  according  as  connec- 
tive tissue  or  cells  predominate.  If  the  former  is  the  prin- 
cipal element,  then  the  tumor  presents  a  hard  consistency 
(as  hard  as  cartilage)  and  is  termed  scirrhus.  In  case  the 
latter  are  more  abundant,  then  it  is  less  firm,  occasionally 
soft  and  succulent.  The  colloid  cancer  as  a  rule  contains 
a  brownish,  somewhat  viscid  fluid.  The  scirrhus  shows  a 
greater  tendency  toward  partial  necrosis  in  its  central  part. 
It  often  forms  a  carcinomatous  ulcer. 

The  primary  intestinal  cancer  frequently  shows  a  ten- 

'  Max  Mnller :  "Beitrage  zur  Kenntniss  der  Metastasenbildung  ma- 
ligner  Tumoren.  "    Inaugural- Dissertation,  Bern,  1892. 


MALIGNANT  GROWTHS.  163, 

dency  to  extend  in  a  circular  direction  perpendicularly  to 
the  lumen  of  the  bowel.  Stenosis  of  the  intestinal  canal 
is  very  often  the  result  of  this  circumstance.  In  case  the 
stricture  is  of  marked  degree,  the  intestine  above  the  stric- 
tured  spot  becomes  greatly  distended  through  stagnating 
fecal  matter  and  gas.  The  bowels  working  hard  to  over- 
come the  obstacle  show  thickened  walls  due  to  hypertrophy 
of  the  muscles.  The  irritating  and  stagnating  contents  in 
the  dilated  part  of  the  intestine  give  rise  to  catarrhal  in- 
jflammation  and  also  to  ulcers.  If  the  stenosis  has  become 
still  more  pronounced,  the  dilatation  of  the  intestine  above 
it  may  be  so  excessive  that  a  rupture  of  its  walls  ultimately 
occurs.  Below  the  stricture  the  intestinal  wall  appears 
thinner,  and  if  the  stricture  is  so  narrow  that  no  contents 
pass  downward,  it  appears  empty  and  contracted.  Occa- 
sionally the  neoplasm  constricting  the  intestinal  lumen 
begins  to  break  down  and  ulcerate,  and  this  partly  removes 
the  occlusion  of  the  intestinal  canal.  This,  however,  does 
not  last  long,  for  as  a  rule  the  cancer  shows  a  tendency  to 
grow  again  and  to  fill  up  the  defect.  Thus  the  free  lumen 
of  the  bowel  is  very  soon  again  occluded. 

This  partial  necrotic  process  will  also  often  cause  more 
or  less  hemorrhage  through  erosion  of  the  smaller  blood- 
vessels. In  case  a  larger  artery  or  vein  opens,  a  severe 
hemorrhage  with  fatal  issue  may  result. 

Cancer  of  the  bowel  often  involves,  besides  the  mucosa 
and  submucosa,  the  muscularis  and  even  the  serosa.  In 
the  latter  event  perforation  occurs  in  rare  instances  before 
adhesions  have  had  time  to  form,  and  may  result  in  fatal 
general  peritonitis.  In  most  instances,  however,  adhe- 
sions have  formed  around  the  involved  area,  and  thus  the 
perforation  causes  merely  a  circumscribed  peritonitis. 
Even  without  the  occurrence  of  perforation  the  cancer  may 


164  DISEASES  OF  THE  INTESTINES. 

progress  from  the  serous  layer  to  the  peritoneum  and  lead 
to  a  carcinomatous  peritonitis,  which  is  often  accompanied 
by  a  hemorrhagic  exudation.  Another  series  of  grave 
complications  is  caused  by  the  extension  of  the  cancerous 
process  to  a  neighboring  organ  which  has  previously  be- 
come agglutinated  to  the  bowel.  The  process  of  disinte- 
gration in  the  cancerous  growth  then  often  establishes  an  ab- 
normal communication  between  the  bowel  and  other  organs. 
Thus  fistulous  openings  may  occur  between  colon  and 
stomach,  between  rectum  and  bladder,  between  rectum  and 
vagina,  between  rectum  and  uterus,  between  large  and 
small  bowels,  or  a  direct  fistulous  opening  may  form  from 
the  bowel  through  the  abdominal  wall. 

Symptomatology. — Cancer  of  the  bowel  develops  quite 
slowly  and  insidiously,  and  in  most  instances  at  the  begin- 
ning gives  rise  to  hardly  any  symjjtoms  at  all.  For  this 
reason  it  can  never  be  detected  at  this  time ;  later,  how- 
ever, general  and  local  symptoms  manifest  themselves. 
While  the  general  symptoms  are  common  to  all  cancers  of 
the  small  and  large  bowels,  the  local  symptoms  will  differ 
according  to  the  location  of  the  tumor,  and  it  will  therefore 
be  necessary  to  consider  the  different  portions  of  the  intes- 
tinal tract  separately. 

A.  General  Symptoms. — The  general  symptoms  of  cancer 
of  the  bowel  are  those  found  in  malignant  growths  of  other 
organs.  Of  these  anaemia  and  cachexia  are  the  most  impor- 
tant. Usually  both  are  present  at  the  same  time.  Some- 
times one  is  more  pronounced  than  the  other.  In  some  in- 
stances a  general  weakness,  pallor,  and  emaciation  are  the 
first  indications  of  a  severe  affection.  There  may  be  as  yet 
no  local  symptoms  whatever  or  a  very  slight  degree  of  con- 
stipation and  scarcely  noticeable  sensation  of  discomfort  in 
the  abdomen.     Loss  of  appetite  and  slight  dyspeptic  sy mp- 


MALIGNANT  GROWTHS.  166 

toms  are  often  encountered.  Fever  is  occasionally  met  with, 
which  is  due  to  a  suppurative  process  and  absorption  of 
pyogenic  matter  into  the  blood.  The  neoplasm  often  gives 
rise  to  disturbances  in  neighboring  organs  by  constricting 
or  dragging  upon  them.  Thus  radiating  pains  from  com- 
pression of  nerves  may  arise  and  in  the  same  manner  dis- 
turbances of  circulation.  CEdema  of  the  lower  extremities 
is  often  encountered,  which  after  lasting  for  weeks  and 
months  may  occasionally  disappear  shortly  before  death. 

Symptoms  of  chronic  intestinal  obstruction  are  often  pres- 
ent. They  develop  either  gradually,  the  constipation  in- 
creasing more  and  more,  or  they  may  appear  more  abruptly. 
The  bowels,  while  formerly  more  or  less  regular,  suddenly 
cease  to  move,  and  even  strong  cathartics  are  of  no  avail. 

The  clinical  features  of  cancerous  obstruction  of  the 
bowel  are  not  different  from  stenosis  of  the  intestine  caused 
by  other  processes,  which  are  described  in  Chapter  IX. 
Such  a  sudden  attack  of  obstruction  of  the  bowel  may  ter- 
minate fatally  in  a  few  days ;  sometimes,  however,  after  a 
total  occlusion  of  the  bowels,  life  continues  much  longer. 
Thus  fecal  retention  of  forty -four  days'  duration,  without 
even  fecal  vomiting,  is  mentioned  by  Heusgen,'  and  an- 
other case  of  eight}  -eight  days'  duration  has  been  reported 
by  Cooper-Forster. '  Diarrhoea  is  frequently  present  in 
cancer  of  the  bowels.  This  often  serves  partly  to  overcome 
the  beginning  obstruction  of  the  intestinal  lumen.  In  some 
cases  diarrha?a  alternates  with  constipation.  In  the  latter 
instance  the  stools  often  bear  signs  of  having  passed  a 
strictured  spot.  They  may  appear  in  the  shape  of  a  tape 
or  in  the  form  of  small,  hard  balls.  These  characteristics 
of  the  evacuation  are,  however,  by  no  means  a  positive 

'  Heusgen  :  Deutsche  med.  Wochenschr. ,  1877. 

*  Cooper- Forster  :  Medical  Times  and  Gazette,  September,  1867. 


156  DISEASES  OP  THE  INTESTINES. 

proof  of  a  real  stricture,  for  they  are  also  met  with  in 
merely  neurotic  conditions.  The  stools  often  contain  an 
admixture  of  mucus,  blood,  or  pus.  In  case  the  progress 
of  the  necrosis  of  the  neoplasm  is  pronounced,  the  stools 
during  that  period  have  a  very  offensive,  almost  unbear- 
able odor.  In  rare  instances  particles  of  tumor  may  be 
discovered  in  the  dejecta,  which  show  under  the  micro- 
scope the  exact  nature  of  the  neoplasm.  If  these  particles 
are  of  a  large  size  (cherry  or  walnut)  they  wiU  be  easily 
discovered  in  the  stools ;  but  if  they  are  minute,  a  thor- 
ough examination  of  the  fecal  matter  will  be  necessary  in 
order  to  find  them.  Washing  out  of  the  bowels  will  often 
be  helpful  to  discover  such  minute  pieces  of  the  growth, 
in  case  the  latter  is  situated  in  the  colon. 

While  all  of  the  above  symptoms  are  of  great  value,  they 
are  unimportant  compared  with  the  physical  signs  of  a 
tumor.  Its  presence  in  a  doubtful  case  in  most  instances 
helps  to  clear  up  the  diagnosis.  The  tumor  is  often  easily 
palpable  and  bears  the  general  characteristics  of  a  cancer- 
ous growth.  It  is  hard  and  presents  an  uneven  nodular 
surface.  Its  size  v§,ries  greatly,  being  often  that  of  a  wal- 
nut and  occasionally  that  of  an  apple  or  still  larger.  In 
the  latter  instance  the  mere  inspection  of  the  abdomen  may 
already  show  the  presence  of  the  tumor.  In  autopsies  the 
neoplasm  is  frequently  found  much  smaller  than  it  ap- 
peared to  be  during  life.  The  cause  of  this  is  the  hyper- 
trophy which  occurs  in  the  walls  of  the  bowel  above  the 
tumor,  together  with  the  accumulation  of  fecal  matter  at 
the  same  place.  The  tumor  is  usually  situated  in  the 
lower  half  of  the  abdomen,  principally  in  the  left  iliac  re- 
gion, not  only  because  this  part  of  the  intestine  is  so  often 
affected,  but  also  because  a  neoplasm  of  other  parts  of  the 
bowel,  if  not  fixed  by  adhesions,  is  as  a  rule  dragged  down 


MALIGNANT  GROWTHS.  157 

by  its  own  weight  into  this  region.  Intestinal  neoplasms 
as  a  rule  show  a  high  degree  of  mobility.  Often  they  can 
be  moved  with  the  hand  in  all  directions  in  the  abdominal 
cavity.  The  only  exceptions  to  this  rule  are  tumors  of  the 
duodenum,  the  sigmoid  flexure,  and  the  caecum,  which  are 
more  or  less  fixed. 

With  regard  to  the  detection  of  the  tumor  a  thorough 
palpation  of  the  abdomen  (if  the  abdominal  walls  are  very 
rigid,  under  ether  or  chloroform  narcosis)  is  necessary.  A 
digital  examination  of  the  rectum,  and,  in  women,  of  both 
rectum  and  vagina,  will  in  most  instances  be  required.  A 
bimanual  examination  will  also  be  found  useful.  In  case 
the  affected  area  in  the  rectum  is  not  accessible  to  digital 
examination,  insi)ection  of  this  organ  and  in  some  instances 
a  manual  examination  under  anaesthesia  with  the  whole 
hand  must  be  resorted  to. 

When  the  disease  is  fully  developed,  peritonitis  (either 
circumscribed  or  general)  often  appears  as  a  complication. 
It  may  be  simply  caused  by  the  inflammatory  processes 
accompanying  the  neoplasm  or  be  of  a  real  cancerous  na- 
ture. While  at  first  it  is  impossible  to  differentiate  these 
two  conditions,  later  on  it  is  as  a  rule  not  difficult  to  deter- 
mine which  of  the  two  is  present.  The  discovery  of  a 
hemorrhagic  exudation  and  of  a  few  nodules  under  the 
abdominal  wall  will  indicate  that  a  cancerous  affection  of 
the  peritoneum  is  present.  An  acute  perforation  peritoni- 
tis is  much  more  rare*and  leads  to  shock  and  sudden  death, 
or  in  the  presence  of  adhesions  to  grave  complications  in 
consequence  of  fecal  abscesses.  If  the  perforation  occurs 
into  adherent  neighboring  organs,  new  communications 
may  be  formed  between  them  and  the  intestine ;  they  ag- 
gravate the  condition  and  are  of  great  clinical  importance. 
The  following  communications  are  frequently  met  with : 


168  DISEASES  OF  THE  INTESTINES. 

1.  Fistula  between  stomach  and  colon.  The  fistulous 
opening  may  freely  communicate  with  both  cavities  or  only 
in  one  direction  on  account  of  the  formation  of  a  valve. 
If  the  passage  has  the  direction  from  the  stomach  into  the 
colon,  symptoms  of  lientery  develop,  and  undigested  and 
unchanged  foods,  as  for  instance  pieces  of  meat,  potatoes, 
spinach,  and  the  like,  appear  in  more  or  less  large  quanti- 
ties in  the  stools ;  often  diarrhoea  manifests  itself  shortly 
after  a  meal  and  examination  of  the  evacuation  shows 
numerous  particles  of  food  from  the  last  meal.  Lavage 
of  the  stomach  performed  in  such  a  case  will  often  show 
that  the  li(iuid  has  escaped  from  the  stomach  in  consider- 
able quantity  and  may  occasionally  be  voided  by  the  rec- 
tum. The  admixture  of  some  coloring  matter  to  the  water 
used  for  lavage  will  facilitate  the  recognition  of  this  condi- 
tion. If  the  communication  has  a  direction  in  the  oppo- 
site way,  namely,  from  the  colon  into  the  stomach,  there 
will  be  an  appearance  of  fecal  matter  in  the  latter.  In 
that  event  the  gastric  contents  always  contain  decomposed 
and  fetid  material,  and  vomiting  of  fecal  matter  is  fre- 
quently the  result.  Inflating  the  colon  with  air  will  often 
cause  a  filling  up  of  the  stomach  with  this  gas,  and  again 
irrigation  of  the  bowelwith  water  (either  clear  or  stained) 
will  be  followed  by  its  appearance  in  the  stomach,  which 
may  be  easily  discovered  by  introducing  a  tube  into  this 
organ  and  evacuating  the  gastric  contents.  If  the  fistulous 
opening  has  a  free  communication  in  both  directions,  then 
symptoms  of  lientery  and  fecal  vomiting  may  be  present 
at  the  same  time  or  they  may  appear  alternately. 

2,  In  case  of  a  comrmmication  between  rectum  and  blad- 
der, small  particles  of  fecal  matter  and  gas  appear  in  the 
latter  organ  and  may  be  voided  through  the  urethra.  They 
give  rise  to  a  putrid  cystitis.    Occasionally  urine  may  pass 


MALIGNANT  GROWTHS.  169 

from  tlie  bladder  into  the  rectum  and  be  discharged  with 
the  stools.  The  recognition  of  the  latter  condition  is, 
however,  more  difficult. 

3.  Communications  between  the  rectum  and  uterus  or 
vagina  are  also  met  with  and  give  rise  to  the  passage  of 
fecal  matter  through  these  organs. 

4.  A  Jistulous  opening  may  exist  between  the  bowel  and 
the  abdominal  icalL  This  fistula  may  discharge  externally 
a  putrid  secretion  having  a  fetid  odor  and  containing  par- 
ticles of  fecal  matter  or  chyle,  depending  upon  its  location, 
whether  in  the  large  or  small  intestine. 

All  these  fistulous  communications  appear  as  a  rule  iu 
the  last  stages  of  the  disease.  They  are,  hewever,  by  no 
means  characteristic  of  cancer  of  the  intestine,  for  they 
may  also,  but  very  rarely,  develop  in  consequence  of  other 
ulcerative  processes  in  the  bowel  (tubercles).  Again  thej^ 
may  be  a  result  of  a  cancerous  growth  in  the  stomach  in- 
volving secondarily  the  intestinal  tract. 

The  urine  does  not  show  anything  characteristic  of  can- 
cer. However,  it  often  contains  large  amounts  of  indican ; 
acetone  and  diacetic  acid  have  also  been  occasionall}'  met 
with. 

B.  Symptoms  Due  to  the  Location  of  the  Neoplasm. — (a) 
Cancer  of  the  duodenum.  In  the  duodenum  the  neoplasm 
almost  always  causes  gastric  symptoms  similar  in  nature 
to  those  of  cancer  of  the  pylorus.  Thus  anorexia,  pains, 
vomiting,  and  dilatation  of  the  stomach  will  be  the  pre- 
dominating features.  If  the  tumor  is  situated  near  the 
pylorus  in  the  superior  horizontal  portion  of  the  duode- 
num it  will  be  quite  movable,  and  a  differential  diagnosis 
between  cancer  of  the  pylorus  and  that  of  the  beginning  of 
the  duodenum  will  hardly  ever  be  possible  during  life.  In 
case  the  neoplasm  is  situated  in  the  descending  part  of  the 


160  DISEASES  OF  THE  INTESTINES. 

duodenum,  in  the  immediate  neighborhood  of  Vater's 
papilla,  icterus  is  often  encountered.  In  such  cases  the 
initial  symptoms  may  be  jaundice  and  sometimes  chills. 
The  icterus  may  remain  stationary  or  vary  in  intensity 
from  time  to  time  according  to  the  degree  of  the  obstruc- 
tion of  the  duct  caused  by  the  neoplasm.  Ulceration  of  the 
tumor  may  for  a  while  open  a  passage  for  the  bile  and  the 
jaundice*  may  then  temporarily  disappear.  If  the  cancer 
is  located  below  Vater's  papilla,  especially  in  the  inferior 
horizontal  part,  the  gastric  contents  will  frequently  show 
tlie  presence  of  a  large  amount  of  bile.  In  the  latter  two 
instances  the  tumor,  if  accessible  to  palpation,  is  not  mov- 
able. On  acoount  of  its  deep  situation  it  can  frequently 
not  be  discovered. 

(b)  Cancer  of  the  small  intestine.  According  to  the  re- 
gion in  which  the  neoplasm  is  situated,  whether  at  the 
beginning  of  the  jejunum  or  in  the  lower  parts  of  the 
ileum,  gastric  or  intestinal  symptoms  will-  jiredomiuate. 
There  may  be  anorexia  and  vomiting,  or,  on  the  other 
hand,  good  appetite  and  apparently  good  stomach  diges- 
tion, but  obstinate  constipation.  The  tumor  is  often  acces- 
sible to  palpation,  and  is  as  a  rule  very  movable. 

(c)  Cancer  of  the  large  howel.  Pains  are  frequently  en- 
countered at  a  localized  spot  in  the  region  of  the  large 
bowel.  They  may  exist  before  a  tumor  can  be  i)alpated 
and  may  be  felt  either  in  its  immediate  neighborhood  or 
in  almost  exactly  opposite  portions  of  the  colon.  Thus 
cancer  of  the  ceecum  may  give  rise  to  pain  in  the  sigmoid 
flexure,  and  vice  versa.  These  pains  are  rarely  severe ;  as 
a  rule  they  consist  merely  in  a  sensation  of  discomfort  or 
in  a  feeling  of  tension.  Besides  these  uncomfortable  sen- 
sations of  a  more  or  less  permanent  nature,  there  may  be 
more  or  less  frequent  attacks  of  colic.     In  the  latter  in- 


MALIGNANT  GROWTHS.  161 

stance  there  may  be  violent  excruciating  pains  in^  the  ab- 
domen, which  may  be  relieved  after  passing  of  flatus  or 
after  a  diarrhoeal  movement.  The  attacks  of  colic  are  fre- 
quentl}'  caused  by  the  commencing  obstruction  of  the  in- 
testine, and  therefore  become  gradually  aggravated  in  na- 
ture. They  may  lead  at  last  to  a  total  obstruction  and  be 
the  immediate  cause  of  death.  Constipation  is  one  of  the 
foremost  symptoms  of  a  neoplasm  of  the  large  bowel.  It 
is  encountered  in  the  great  majoritj^  of  cases;  in  some  in- 
stances it  forms  the  first  symptoms  of  the  disease;  at  first 
it  may  be  slight  in  nature,  but  becomes  steadily  more  ob- 
stinate. Ten  or  twenty  days  may  pass  without  a  sponta- 
neous evacuation,  and  even  cathartics  are  very  slow  in  their 
action.  The  constii)ation  as  a  rule  is  accompanied  by  the 
usual  symptoms  resulting  from  it,  tension  and  fulness  in 
the  abdomen,  poor  appetite,  occasionally  pains.  The  con- 
stipation may  at  times  disappear  and  give  place  to  a  pe- 
riod of  diarrhoea.  In  some  instances  diarrhoeal  evacu- 
ations may  exist  for  many  weeks,  and  they  may  be  the 
predominating  feature  of  the  disease. 

(cf)  Cancer  of  the  rectum.  The  symptoms  met  with  in 
cancer  of  the  rectum  resemble  more  or  less  those  of  a  neo- 
plasm of  the  upper  j^ortion  of  the  large  bowel.  Here,  how- 
ever, the  diagnosis  can  be  made  with  greater  ease  and  cer- 
tainty. In  most  instances  rectal  cancer  can  be  discovered 
by  a  digital  examination  of  the  rectum.  By  means  of  the 
latter  we  may  discover  a  mass  lying  right  beneath  the  mu- 
cous membrane  of  the  rectum,  over  which  the  mucosa  can 
be  slightly  moved  or  not  at  all  if  it  is  adherent.  The  sur- 
face may  feel  uneven  and  somewhat  hard.  Sometimes  the 
finger  encounters  a  constriction  through  which  it  cannot 
easily  pass ;  the  tissues  here  present  the  same  character- 
istics as  just  described.  Occasionally  an  ulcerated  area 
11 


162  DISEASES  OP  THE  INTESTINES. 

can  be  iiiscovered  on  the  surface  of  the  neoplasm.  In  can- 
cer of  the  rectum  situated  high  up  (not  accessible  to  digital 
examination),  several  clinicians  have  advised  examination 
with  the  whole  hand  passed  through  the  rectum.  This, 
however,  can  be  done  only  under  chloroform  narcosis  and 
is  not  free  from  danger.  Such  an  examination  may  in  rare 
instances  cause  rupture  of  the  intestinal  wall  as  stated  by 
Volkmann.'  Inspection  of  the  rectum  by  means  of  Kellj's 
speculum  can  be  easily  performed  and  aids  us  in  discover- 
ing a  neoplasm  situated  quite  high  up  in  the  rectum,  even 
if  not  accessible  to  digital  examination.  The  latter  instru- 
ment may  also  be  used  in  neoplasms  of  the  lowest  part  of 
the  bowel,  although  its  use  here  is  not  of  much  impor- 
tance, as  the  palpating  finger  gives  u*  enough  certainty  in 
making  the  diagnosis. 

Cancer  of  the  rectum  is  as  a  rule  accompanied  by  severer 
pains  than  that  of  the  large  bowel.  These  as  a  rule  are 
local  in  character.  They  often  radiate  toward  the  csBCum 
and  the  lower  lumbar  region,  toward  the  bladder  and  geni- 
tal organs,  and  sometimes  in  the  direction  of  the  sciatic 
nerves.  In  case  the  neoplasm  involves  the  anus,  there  is 
an  exacerbation  of  the  pain  at  each  evacuation.  Tenesmus 
is  constantly  present  in  the  latter  instance.  If  such  a  neo- 
plasm of  the  lower  parts  of  the  rectum  becomes  ulcerated, 
the  tortures  of  the  afflicted  person  can  hardly  be  described. 
The  patient  as  a  rule  is  afraid  of  having  an  evacuation,  and 
tries  to  keep  it  back  as  long  as  possible.  At  last  there  is 
a  movement  containing  fecal  matter,  mucus,  blood,  and 
sometimes  pus,  under  most  excruciating  pains. 

Leube  has  directed  attention  to  the  fact  that  hemor- 
rhoids are  frequently  associated  with  the  neojjlasm  of  the 

'  Volkmann  :  "  Ueber  den  Mastdarmkrebs.  "  Volkmann 's  Sammlung 
klin.  Vortraege,  No.  131. 


MALIGNANT  GROWTHS.  163 

rectum.  This  is  of  importance,  as  it  shows  that  the  pres- 
ence of  hemorrhoids  should  not  lead  one  to  abstain  from 
digital  rectal  examination.  If  a  patient  has  complained  of 
constipation  for  a  short  period  (a  few  months)  and  hemor- 
rhoids have  developed  during  this  time,  the  latter  are 
rather  indicative  of  a  more  serious  condition,  and  a  digital 
examination  of  the  rectum  should  always  be  undertaken 
under  such  circumstances. 

Course. — An  uncomplicated  intestinal  cancer  may  last 
for  years.  Frequently,  however,  the  time  is  much  shorter. 
Many  complications  are  liable  to  occur — hemorrhages,  per- 
foration peritonitis,  rupture  of  the  intestines,  ileus,  auto- 
intoxication, extension  of  the  cancer  to  other  organs,  and 
metastases.  On  account  of  these  many  possibilities  the 
life  of  the  patient  may  be  shortened,  and  it  is  hardly  pos- 
sible to  foresee  its  duration.  In  some  instances  a  condi- 
tion of  coma  (coma  carcinomatosum)  appears  quite  earl}-. 
It  is  generally  assumed  that  the  latter  is  due  to  auto-intoxi- 
cation, either  by  the  products  of  decomposition  of  the  in- 
testinal contents  or  by  the  toxins  of  the  cancer.  Ewald  in 
such  a  case  succeeded  in  isolating  a  body  from  the  urine 
belonging  to  the  group  of  diamins.  In  cancer  of  the 
duodenum  the  general  nutrition  suffers  very  early  and  ex- 
tensively, and  for  this  reason  the  duration  of  life  is  short. 
In  cancer  of  the  rectum  nutrition  is  well  maintained  for  a 
long  period,  and  for  this  reason  the  duration  of  life  in  the 
absence  of  complications  is  quite  long  (about  four  years). 
In  case  anaemia  of  a  high  degree  supervenes,  a  marasmic 
thrombosis  may  develop  and  the  patient  may  die  in  conse- 
quence of  an  embolus  of  the  lungs.  If  intestinal  cancer  is 
unattended  with  complications,  death  often  results  in  con- 
sequence of  general  exhaustion. 

Diagnosis. — The  diagnosis  of  intestinal  cancer  can  be 


164  DISEASES  OP  THE  INTESTINES. 

made  with  certainty  in  the  following  instances:  1.  If  by 
abdominal  or  rectal  palpation  a  tumor  can  be  detected 
which  is  situated  in  the  small  or  large  bowel,  and  accom- 
panied by  symptoms  of  cachexia  and  disturbances  of  defe- 
cation. 2.  The  presence  of  a  tumor  as  just  described,  and 
the  discovery  of  small  particles  of  the  neoplasm  in  the 
evacuation  giving  microscopically  the  appearance  of  a  can- 
cerous growth.  3.  Gradually  increasing  disturbances  of 
the  bowel  for  a  few  months  in  a  heretofore  healthy  person, 
accompanied  by  cachexia  and  symptoms  of  a  beginning  or 
already  developed  stricture  of  the  bowels  and  the  presence 
of  a  small  particle  of  growth  in  the  stools,  giving  as  above 
microscopically  the  picture  of  cancer. 

If  there  is  no  tumor  and  if  nothing  cancerous  is  found 
in  the  stools,  the  diagnosis  can  never  be  made  with  cer- 
tainty. A  probable  diagnosis  of  intestinal  cancer  will 
have  to  be  made  if  cachexia  is  present,  together  with 
symptoms  of  gradually  developing  intestinal  disturbances, 
indicating  the  beginning  of  an  obstruction  of  the  bowel,  in 
a  middle-aged  or  elderly  person  who  has  been  well  up  to  a 
few  months  before. 

Prognosis. — The  prognosis  of  intestinal  cancer  is  always 
unfavorable.  Unless  an  early  operation  and  total  ex- 
cision of  the  growth  is  resorted  to,  a  fatal  issue  is  sure  to 
follow,  although  the  exact  duration  of  life  can  hardly  be 
predicted,  the  latter  depending  upon  subsequent  complica- 
tions. 

Treatment. — A  cure  is  possible  only  by  a  total  and  thor- 
ough removal  of  the  growth.  We  must  therefore  always 
endeavor  to  make  the  diagnosis  as  early  as  possible  and 
advise  an  immediate  operation  whenever  feasible.  Cancer 
of  the  rectum  can  be  recognized  quite  early  and  resection 
of  the  neoplasm  is  here  followed  by  brilliant  results.     If 


MALIGNANT  GROWTHS.  166 

the  tumor  is  located  farther  up  in  the  large  bowel  or  in 
the  small  intestine,  then  the  results  of  an  operation  are  not 
so  ijromising,  for  here  the  recognition  of  the  growth  is  pos- 
sible only  at  an  advanced  period,  and  by  that  time  often 
adhesions  with  other  organs  and  cancerous  infection  of  the 
glands  have  already  taken  place.  Excision  of  the  tumor 
and  resection  of  the  intestine  in  the  neighborhood  of  the 
neojjlasm  with  an  end-to-end  anastomosis  should  be  prac- 
tised whenever  feasible.  In  case,  however,  total  resection 
is  impossible,  an  entero-enterostomy  or  entero-colostomy, 
or  if  the  cancer  is  situated  in  the  rectum,  a  colostomy  (ar- 
tificial anus)  will  be  of  benefit.  These  operations  are  pal- 
liative in  nature  and  prolong  life,  at  the  same  time  making 
it  more  comfortable.  They  are  intended  to  allay  the  symp- 
toms of  obstruction  and  to  carry  the  fecal  matter  over  a 
new  route,  not  passing  through  and  thus  not  irritating  the 
cancerous  area.  In  some  instances  of  inoperable  cancer  of 
the  rectum  curettage  followed  by  the  application  of  the 
thermo-cautery  is  of  benefit  for  a  short  period. 

Aside  from  these  surgical  means  the  treatment  should 
be  symptomatic.  The  diet  should  consist  of  foods  con- 
taining plenty  of  nourishment  but  very  little  indigestible 
residue,  thus  forming  only  a  small  quantity  of  fecal  mat- 
ter. If  there  is  stagnation  of  the  intestinal  contents, 
cathartics  will  have  to  be  given  in  order  to  litiuefy  the 
fecal  matter.  This  can  be  done  by  means  of  castor  oil, 
rhubarb,  magnesium  sulphate,  and  so  on.  If  the  neoplasm 
is  located  in  the  large  bowel,  irrigations  with  warm  oil  or 
water  are  preferable.  The  pains  should  be  allayed  by 
means  of  warm  baths  and  cataplasms,  but  if  these  fail, 
by  narcotic  remedies,  such  as  morphine,  opium,  codeine, 
or  belladonna;  suppositories  being  here  most  suitable. 
Eventual  complications  should  be  treated  as  such. 


166  DISEASES  OF  THE  INTESTINES. 

Sarcoma  and  Lympho-Sarcoma. 

Sarcoma  of  the  intestine  is  a  much  rarer  affection  than 
cancer.  According  to  Kundrat, '  in  the  Wiener  Allgemeine 
Krankenhaus  between  the  years  1882  to  1893  there  were 
2,125  autopsies  on  cases  of  cancer.  Of  this  number  243 
were  cancers  of  the  intestines.  In  the  same  period  of  time 
there  were  274  necropsies  on  patients  with  sarcoma,  of 
which  3  were  located  in  the  intestines.  Among  61  lympho- 
sarcomata  9  were  in  the  intestines.  On  the  whole  the 
symptomatology  of  these  malignant  neoplasms  coincides 
with  that  of  cancer  of  the  intestines.  There  are,  however, 
a  few  points  in  which  they  differ  from  intestinal  cancer.* 
While  carcinoma  is  most  frequently  found  in  the  lower 
portions  of  the  large  bowel,  sarcoma  shows  a  greater  i)redi- 
lection  for  the  small  intestine  and  the  upper  portion  of  the 
large  bowel.  Thus,  according  to  Nothnagel,  among  9  cases 
of  sarcoma  of  the  intestines  1  was  located  in  the  duode- 
num, 3  in  the  jejunum,  3  in  the  ileum,  and  2  in  the  caecum. 

Sarcoma  of  the  intestines  shows  very  rapid  progress, 
and  metastases  in  other  organs  are  very  early  found.  The 
duration  of  life  is  much  shorter  than  in  cancer,  being  in 
most  cases  about  but  nine  months.  There  is  only  one  in- 
stance mentioned  in  literature  in  which  a  patient  lived  one 
and  three-quarter  years  after  the  first  appearance  of  symp- 
toms. Symptoms  of  obstruction  which  are  so  frequently 
found  in  cancer  of  the  intestines  are  very  rarely  if  ever  met 
with  in  sarcoma.  The  tumor  as  a  rule  extends  over  a  large 
part  of  the  intestines,  but  does  not  occlude  the  canal. 
Cachexia  and  ansemia  belqpg  to  the  early  symptoms,  and 
are  much  more  pronounced  than  in  cancer.     The  progno- 

'  Kundrat :  Qerhardt's  "  Handbuch  der  Kinderkrankheiten,  "  Bd.  iv., 
2te  Abtheilung.  TQbingen,  1880. 


BENIGN  TUMORS.  167 

sis  of  this  form  of  tumor  of  the  intestines  is  absolutely 
fatal.  Even  in  cases  in  which  an  operation  is  performed 
quite  early,  it  is  as  a  rule  not  of  much  benefit  on  account 
of  the  numerous  metastases  which  develop  so  early ;  and 
on  this  account  Madelung '  even  hesitates  to  advise  surgi- 
cal interference. 

BENIGN  TUMORS  OF  THE  INTESTINE. 

Of  the  benignant  neoplasms  the  following  forms  are 
occasionally  met  with  in  the  intestine:  adenoma,  fibro- 
ma, lipoma,  mj'oma,  angioma,  and  cyst.  These  growths 
are  termed  polypi  if  they  have  a  pedicle.  Occasionally 
they  have  a  large  base  and  form  only  a  small  ijrominence 
over  the  surface.  The  polypi  are  usually  of  small  size, 
that  of  a  cherry  or  plum ;  rarely  they  are  larger,  pear-sized 
or  greater  still.  As  a  rule  they  are  covered  with  normal 
mucous  membrane.  Although  they  are  found  almost  every- 
where in  the  intestinal  tract,  they  occur  most  frequently  in 
the  rectum  (according  to  Rosenheim  in  eighty  per  cent). 

Among  the  benign  tumors  the  adenomata  are  most  fre- 
quently met  with.  They  arise  from  the  mucosa,  have  a 
typical  acinous  structure,  and  are  attached  to  the  mucous 
membrane  either  by  a  broad  base  or  by  a  pedicle.  In  the 
latter  instance  they  form  polypoid  excrescences  which  may 
cover  long  distances  of  the  intestinal  canal,  existing  in  large 
numbers.  Ewald  refers  to  a  specimen  in  his  possession  in 
which  the  inner  wall  of  the  colon  was  covered  from  the 
splenic  curvature  to  the  sigmoid  flexure  with  such  numer- 
ous polypi  that  they  projected  from  the  mucous  membrane 
like  tassels  from  a  ribbon.  The  whole  specimen  looked 
somewhat  like  a  gigantic  bunch  of  grapes.  The  polypi  are 
most  often  met  with  in  children  from  the  fourth  to  the 
'  Madelung :  Centralbl.  f.  Cliirurgie,  1892.  No.  30. 


168  DISEASES  OP  THE  INTESTINES. 

seventh  year,  although  they  also  occur  in  grown-up  per- 
sons. 

With  regard  to  symptoms  the  benign  tumors  located  in 
the  upper  parts  of  the  intestinal  tract  cause  hardly  any 
disturbances '  at  all.  Sometimes,  however,  especially  if 
they  are  present  in  larger  numbers,  they  may  give  rise  to 
hemorrhages  and  catarrhal  affections.  On  account  of  their 
small  size  and  soft  consistency  it  is  almost  impossible  to 
discover  them  by  palpation  through  the  abdominal  wall. 
In  very  rare  instances  the}"  may  give  rise  to  serious  symp- 
toms by  occluding  the  intestinal  lumen  or  by  causing  in- 
vagination. The  benign  tumors  located  in  the  rectum 
more  frequently  give  rise  to  disturbances.  Thus  tenesmus 
and  difficult  defecation  are  often  met  with;  hemorrhages 
also  occur  frequently.  Sometimes  such  a  polypus,  if  situ- 
ated near  the  anus,  may  protrude  through  this  opening 
during  defecation  and  give  rise  to  severe  pains.  Occasion- 
ally a  polypus  is  torn  off  from  the  intestinal  wall  and 
passed  with  the  stools.  In  such  an  event  the  symptoms, 
if  there  have  been  any,  suddenly  disappear. 

Whenever  these  tumors  are  situated  in  the  lower  rec- 
tum they  are  accessible  to  direct  examination  and  treat- 
ment. The  latter  consists  in  removing  them  by  galvano- 
cautery  or  by  direct  surgical  measures. 


CHAPTER  VII. 

HEMORRHOIDS. 

Synonyms :  Phlebectasia  hemorrhoidalis.     Piles. 

Definition. — Diffuse  or  circumscribed  varicose  dilata- 
tions of  the  hemorrhoidal  veins  situated  either  in  the  sub- 
cutaneous tissue  of  the  external  surface  of  the  anus  or  in 
the  submucous  tissue  of  the  lower  portion  of  the  rectum. 

Etiology. — The  affection  under  consideration  is  quite 
frequently  met  with.  It  occurs  more  often  in  men  than  in 
women  and  very  rarely  in  children.  While  in  olden  times 
it  was  believed  that  hemorrhoids  were  due  to  a  faulty  state 
of  the  general  circulation  or  dyscrasia,  it  is  now  generally  ac- 
cepted that  they  are  the  result  of  merely  local  disturbances. 
The  development  of  hemorrhoidal  varices  takes  place  in 
the  same  manner  as  that  of  varices  of  other  regions  of  the 
body,  principally  by  mechanical  influences.  The  reason 
why  these  phlebectases  are  formed  so  often  in  the  hemor- 
rhoidal plexus  is  as  follows:  1.  The  hemorrhoidal  veins 
occup3^  a  low  position  of  the  body,  no  matter  whether  in 
the  standing  or  in  the  recumbent  posture.  2.  They  are 
often  unduly  compressed  by  the  contraction  of  the  muscles 
situated  in  the  lower  end  of  the  rectum  and  by  fecal  masses 
accumulated  here.  The  circulation  is  thus  at  certain  times 
obstructed  or  altogether  arrested.  3.  The  hemorrhoidal 
veins  are  not  provided  with  valves,  and  thus  blood  which 
has  ijassed  through  them  can  be  easily  forced  back.  4. 
The  rectal  veins  are  the  remotest  branches  of  the  portal 


170  DISEASES  OF  THE  INTESTINES. 

vein  in  which  there  is  normally  but  a  low  degree  of  pres- 
sure, and  in  which  circulation  is  easily  retarded  by  dis- 
turbances of  the  liver.  As  all  these  factors  exist  even 
under  normal  conditions  it  is  readily  conceivable  that 
phlebectases  are  found  in  the  majority  of  people;  usually, 
however,  they  do  not  reach  a  marked  development,  and 
for  this  reason  do  not  give  rise  to  complaints. 

All  conditions  which  tend  to  produce  lasting  hypergemia 
of  the  lower  portion  of  the  rectum  give  rise  to  the  develop- 
ment of  hemorrhoids.  Too  prolonged  sedentary  or  stand- 
ing occupations  predispose  to  them.  In  this  way  hemor- 
rhoids occur  in  clerks,  students,  some  artisans,  for  instance, 
shoemakers,  tailors,  and  cavalrymen,  seamstresses  and 
washwomen,  etc.  High  livers  and  people  who  are  used 
to  strongly  seasoned  or  fatty  foods  also  often  suffer  from 
piles  on  account  of  the  great  fulness  of  the  portal  circula- 
tion under  these  conditions.  Habitual  constipation  also 
favors  their  development.  The  use  of  strong  cathartics 
like  aloes,  colocynth,  gamboge,  etc.,  irritates  the  large 
bowel  in  a  marked  degree  and  often  gives  rise  to  hemor- 
rhoids. Diseases  of  the  uterus  which  lead  to  an  enlarge- 
ment of  this  organ  and  also  pregnancy  are  predisposing 
causes.  In  a  similar  way  affections  of  the  prostate  and 
tumors  of  the  bladder  as  well  as  of  other  organs  situated 
in  the  small  pelvis  often  produce  hemorrhoids.  All  dis- 
eases of  the  liver  which  are  accompanied  by  a  congestive 
state  of  the  portal  circulation  exert  a  direct  influence  upon 
their  formation.  Diseases  of  the  heart  and  lungs  fre- 
quently cause  congestion  of  the  inferior  vena  cava  and 
Indirectly  also  of  the  rectal  veins,  thus  predisposing  to 
the  affection  under  consideration. 

Hemorrhoids  are  most  frequently  developed  between  the 
ages  of  thirty  and  fifty  years.     They  are  extremely  rare 


HEMORRHOIDS.  171 

in  infants  and  children.  With  regard  to  frequency  the 
male  sex  seems  to  be  more  often  afflicted  than  the  female. 
Some  races  show  a  special  predisposition  to  this  disease, 
depending  most  probabl}^  ui)on  their  mode  of  living  and 
their  diet.  Whether  heredity  plays  a  part  in  the  develop- 
ment of  hemorrhoids  is  yet  unsettled. 

Morbid  A)iatomij. — In  some  instances  the  hemorrhoidal 
veins  are  evenly  dilated  and  can  be  noticed  as  bluish-red 
and  tortuous  vessels  encircling  the  external  anal  opening. 
At  the  same  time  there  may  be  no  special  varicose  swell- 
ings; more  frequently,  however,  besides  the  general  con- 
gested condition  of  the  veins  there  are  isolated  varicose 
protrusions  which  may  range  in  size  from  a  pea  to  a  wal- 
nut. They  vary  greatly  in  shape:  sometimes  they  are 
round,  sometimes  flat,  sometimes  again  irregular.  Their 
size  greatly  changes  from  time  to  time  in  the  same  person. 
After  defecation  as  a  rule  they  grow  smaller.  Internal 
hemorrhoids  appear  as  soft  nodules  of  a  bluish  hue  and 
have  thin  walls.  They  often  develop  to  a  considerable 
size  and  make  defecation  difficult.  As  a  rule,  hemorrhoids 
occur  as  multiple  nodules,  which  may  cover  the  mucous 
membrane  at  different  places,  or  they  may  encircle  the 
external  surface  of  the  anus,  or  be  situated  above  the  inter- 
nal sphincter.  Internal  and  external  hemorrhoids  may 
also  be  present  at  the  same  time.  Thus  Cruveilhier  '  de- 
scribed a  case  in  which  there  existed  a  wreath  of  external 
hemorrhoids  around  the  anal  opening,  another  above  the  in- 
ternal sphincter,  and  a  third  a  few  centimetres  farther  up. 

External  hemorrhoids  are  at  first  covered  with  normal 
epidermis  which  can  be  moved  over  them.  Later,  how- 
ever, through  inflammatory  processes  the  cutis  becomes 
adherent  to  the  varicose  nodule.     At  the  same  time  the 

'  Cruveilhier  :  "Traite  d'anatomie  patliologique  generale,  "  1849. 


172  DISEASES  OP  THE  INTESTINES. 

skin  covering  the  nodule  grows  thinner  through  the  steady 
pressure  iki  which  it  is  subjected,  and  it  may  reach  a  point 
when  it  breaks  open  after  a  forced  defecation.  The  same 
remarks  also  apply  to  internal  hemorrhoids  in  which  the 
cutaneous  covering  of  external  hemorrhoids  is  represented 
by  the  mucous  membrane  of  the  bowel.  This  also  be- 
comes adherent,  thinned,  and  may  ultimately  rupture. 

Internal  piles  are  best  divided,  according  to  Allingham, ' 
into  the  three  following  varieties : 

1,  Capillary  Piles.  These  present  small,  florid,  rasp- 
berry-looking tumors  or  rather  vascular  areas  upon  the 
mucous  membrane,  having  a  granular  spongy  surface  and 
bleeding  on  the  slightest  touch;  they  are  often  situated 
rather  high  in  the  bowel ;  in  structure  they  consist  almost 
entirely  of  hypertrophic  capillary  vessels  and  spongy  con- 
nective tissue.  They  resemble  arterial  naevi  very  closely, 
indeed,  in  their  microscopical  structure,  except  that  they 
are  covered  externally  by  a  very  much  thinner  membrane 
and  consequently  are  readily  made  to  bleed. 

2.  Arterial  Piles.  These  appear  as  tumors  varying  in 
size,  sessile  or  somewhat  pedunculated,  attaining  sometimes 
very  considerable  dimensions,  glistening  or  slightly  villous 
on  their  surface,  slippery  to  the  touch,  hard  and  vascular 
with  an  artery  often  as  large  as  the  radial  entering  their 
Hpi)er  part.  When  they  are  villous  on  their  surface,  they 
bleed  very  freely  and  for  some  reason  or  other  have  formed 
and  grown  very  rapidly.  On  dissecting  one  of  these  tumors 
one  will  find  that  it  consists  of  numerous  arteries  and 
veins  frequently  anastomosing,  tortuous,  and  sometimes 
dilated  into  pouches,  and  of  a  stroma  of  cell  growth  and 
connective  tissue,  the  latter  most  abundant. 

•William  Allingham  and  Herbert  W.  Allingham:  "The  Diagnosis 
and  Treatment  of  Diseases  of  the  Rectum.  "    London,  1896,  p.  113. 


HEMORRHOIDS.  173 

3.  Venous  Piles.  In  these  the  venous  system  predomi- 
nates. The  tumors  are  often  very  large  and  are  sometimes 
the  size  of  a  hen's  egg.  They  are  bluish  or  livid  in  color. 
The  surface  may  be  smooth  and  shiny  or  pseudocutaneous. 

External  and  internal  piles  often  present  themselves  as 
nodules  situated  closely  to  each  other  and  sometimes  coa- 
lescing ;  thus  larger  tumors  arise.  In  these  hemorrhoidal 
varices  important  structural  changes  frequently  take  place. 
While  at  first  soft,  they  vn&x  grow  quite  hard  by  the  for- 
mation of  blood  clots  or  by  a  process  of  calcification.  In- 
flammatory processes  in  the  neighboring  tissue  have  a 
tendency  to  increase  their  size  and  to  make  them  more 
firm. 

Internal  piles  are  often  pushed  downward  during  the  act 
of  defecation.  In  this  manner  the  mucous  membrane  of 
the  base  of  the  tumor  is  subjected  to  greater  traction,  and 
thus  ultimately  a  pedicle  is  formed.  Such  nodules  pro- 
vided with  more  or  less  long  pedicles  and  situated  near 
the  internal  sphincter  very  frequently  slip  out  from  the 
anus  at  each  defecation.  When,  however,  they  are  not 
especially  large,  they  spontaneously  return  into  the  rectum 
after  defecation  is  finished.  If  they  are  of  considerable 
size,  it  sometimes  happens  that  they  become  incarcerated 
by  the  external  sphincter,  and  if  not  carefully  replaced, 
inflammation  may  develop  and  give  rise  to  intense  pains. 
Occasionally  they  may  even  become  gangrenous  and  ulti- 
mately drop  oflf.  In  some  instances  hemori'hoids  undergo 
retrograde  changes,  become  smaller,  and  even  disappear 
entirely.  Flaps  of  skin  hanging  near  the  anus  and  pre- 
senting a  brownish  color  are  often  the  remnants  of  pre- 
vious piles.  External  i)iles  sometimes  give  rise  to  the 
formation  of  warts  and  their  surface  assumes  an  uneven 
and  wrinkled  appearance.     Internal  hemorrhoids  are  often 


174  DISEASES  OF  THE  INTESTINES. 

complicated  by  inflammatory  processes  of  the  neighboring 
tissues.  Such  processes  give  rise  to  the  formation  of  ul- 
cers, proctitis,  and  periproctitis.  In  the  latter  instance 
an  abscess  may  be  formed,  which  may  open  either  exter- 
nally or  internally,  sometimes  both  ways.  Thus  a  com- 
plete rectal  fistula  originates. 

In  internal  hemorrhoids  the  mucous  membrane  of  the- 
rectum  almost  always  exhibits  the  signs  of  a  chronic  ca- 
tarrh. Its  surface  is  swollen,  succulent,  and  often  covered 
with  a  thick  layer  of  mucus.  Occasionally  there  may  be 
some  pus.  The  proctitis  accompanying  piles  may  be  either 
the  cause  or  the  sequel  of  the  latter ;  sometimes,  however, 
both  may  be  due  to  some  other  factor. 

Symptomatology. — Most  of  the  symptoms  produced  by 
hemorrhoids  are  generally  of  a  local  character.  They 
greath'  vary  in  the  different  varieties  of  piles.  In  the 
early  stage  of  external  pile  there  occur  off  and  on,  espe- 
cially after  indiscretions  in  eating  and  drinking  (princi- 
pally effervescent  wines  or  strong  alcoholic  beverages), 
attacks  caused  by  an  increased  congestion  of  the  hemor- 
rhoids. These  attacks  may  be  described  as  follows:  A 
sensation  of  fulness  or  clogging  and  slight  pulsation  in  the 
anus  are  felt  by  the  patient.  Moderate  constipation  exists, 
compelling  the  patient  to  strain  more  than  ordinarily. 
Itching  of  the  anal  region  and  the  perineum  frequently 
annoy  the  patient,  especially  soon  after  retiring,  and  may 
keep  him  awake  for  quite  some  time.  On  awaking  in  the 
morning  the  patient  finds  the  anus  tender  and  swollen, 
and  after  a  movement  a  few  stains  of  blood  are  discov- 
ered on  the  paper.  Such  an  attack  will,  as  a  rule,  pass  off 
very  quickly  if  the  patient  lives  rationally  and  avoids  the 
predisposing  causes;  if  not,  the  attack  will  quickly  recur 
with  greater  intensity  and  gradually  assume  a  severer  type. 


HEMORRHOIDS.  175 

External  piles  may  become  swollen  and  oedematous,  and 
are  then  extremely  painful  to  touch.  Sometimes  there 
may  be  ulceration,  or  suppuration  may  take  place  and 
small  painful  fistulae  may  form.  The  venous  tumors  now 
and  then  irritate  the  sphincter  and  levator  ani  muscles  and 
produce  spasm  of  the  latter.  The  piles  are  then  occasion- 
ally drawn  up  into  the  anus  and  pinched  by  the  latter. 
This  causes  a  great  deal  of  pain  and  keeps  the  patient 
awake  during  the  night.  A  feeling  of  throbbing  and  a 
sensation  as  of  a  foreign  body  in  the  anus  exist.  A  fre- 
quent desire  for  defecation  is  thereby  produced  and  the 
patient,  as  a  rule,  is  inclined  to  attempt  to  expel  the  for- 
eign body  by  forcible  straining,  which  of  course  only 
aggravates  the  pain.  Under  these  circumstances  the 
patient  can  hardly  sit  down  nor  can  he  walk  about  com- 
fortably, and  on  coughing  and  sneezing  experiences  great 
suffering  on  account  of  the  constriction  of  the  involved 
diseased  parts.  During  a  movement  of  the  bowe^and  for 
some  hours  afterward  the  pains  are  greatly  increased. 
The  patient  is  unable  to  attend  to  his  daily  occupation. 
General  symptoms  like  fever,  anorexia,  dizziness,  'severe 
constipation,  may  accompany  the  local  manifestations. 

Of  the  internal  hemorrhoids,  the  capillary  variety,  being 
small  and  only  slightly  elevated  above  the  mucous  surface, 
gives  rise  to  scarcely  any  trouble.  As  a  rule,  there  is  no 
pain.  Occasionally,  however,  ulceration  takes  place  which 
may  cause  considerable  suffering. 

Arterial  and  venous  hemorrhoids  give  rise  to  many  more 
symptoms.  In  case  the  sphincter  muscles  are  relaxed,  the 
hemorrhoids  often  protrude  on  the  slightest  exertion. 
This  also  often  occurs  at  stool.  At  first  they  spontane- 
ously return  within  the  sphincter  after  the  bowels  have 
moved  or  whenever  the  exertion  has  ceased.     Later  in  the 


176  DISEASES  OP  THE  INTESTINES. 

course  of  the  disease,  however,  the  patient  is  compelled  to 
return  them  with  the  finger.  In  still  more  advanced  cases 
they  never  remain  long  within  the  sphincter  and  pro- 
trude very  often  whenever  the  least  exertion  is  made.  In 
this  manner  the  hemorrhoids  cause  much  discomfort. 
They  also  discharge  a  gummy  acrid  mucus  which  keeps 
the  parts  constantly  moist  and  leads  to  excoriations  around 
the  anus,  and  also  favors  the  development  of  cutaneous 
excrescences.  Patients  with  fully  developed  internal  hem- 
orrhoids experience  a  great  deal  of  suflfering  during  defe- 
cation. They  also  feel  quite  uncomfortable  for  some  time 
afterward,  occasionally  to  such  a  degree  that  they  have  to 
lie  down.  When  walking  they  are  always  conscious  of  the 
fact  that  they  have  an  anus. 

In  other  instances  in  which  the  sphincter  ani  is  strong 
and  tight,  the  piles  in  coming  down  become  nipped  and 
their  return  is  rendered  difficult  and  painful. 

The  fymptom  from  which  the  hemorrhoids  originally 
derived  their  name,  namely,  hemorrhage,  is  common  to  all 
varieties  of  piles,  although  it  is  by  no  means  constant.  In 
many  instances  it  is  absent,  or  it  does  not  play  any  essen- 
tial part,  especially  in  external  piles.  In  some  patients  a 
more  or  less  considerable  hemorrhage  takes  place  at  cer- 
tain intervals,  appearing  periodically,  occasionally  with 
great  regularity.  A  few  premonitory  signs,  consisting  in 
painful  sensations  in  the  back  and  around  the  anus,  con- 
stipation, and  other  indefinite  nervous  symptoms  usually 
precede  for  a  few  days  the  beginning  hemorrhage.  The 
blood  as  a  rule  then  appears  at  first  in  small  quantities 
gradually  increases  in  amount,  and  the  hemorrhage  stops 
on  the  fifth  or  sixth  day  after  its  commencement.  Physi- 
cians in  olden  times — and  some  of  the  laity  even  nowadays 
— looked  upon  the  hemorrhage  as  an  important  event,  free- 


HEMORRHOIDS.  177 

ing  the  system  of  vicious  material.  This  is  the  reason  why 
formerly  the  hemorrhoidal  bleeding  was  termed  the  golden 
flow.  Nowadays  we  do  not  attach  any  particular  import- 
ance to  these  hemorrhages.  Their  regularity  or  the  perio- 
dicity of  their  appearance  is  simply  attributable  to  the 
fact  that  the  time  necesary  for  the  filling  up  of  the  nodules 
until  they  rupture  is  usually  of  the  same  length. 

In  some  instances  there  are  transient  hemorrhages,  last- 
ing a  shorter  or  longer  period.  Ordinarily  the  patients  feel 
relieved  after  the  bleeding ;  occasionally  they  remain  quite 
well  for  a  long  time,  sometimes  for  a  year  or  two,  until 
there  is  suddenly  a  new  hemorrhage.  In  the  latter  case 
the  hemorrhage  is  commonly  caused  by  some  unusual  oc- 
currence ;  thus,  a  very  copious  meal,  a  long  ride  on  horse- 
back, or  an  excess  in  venery  may  bring  it  on. 

In  another  class  of  patients  there  may  be  continuous 
small  hemorrhages.  These  occur  more  frequently  in  cases 
of  capillary  hemorrhoids.  The  quantity  of  blood  lost  at 
each  action  of  the  bowel  is  small,  but  being  steady  it  be- 
comes a  serious  strain  upon  the  patient's  constitution  and 
may  give  rise  to  sesrere  forms  of  anaemia  and  even  per- 
nicious anaemia. 

The  blood  discharged  from  piles  is  either  of  a  bright 
red  or  a  dark  brown  color,  depending  upon  its  origin  from 
arteries  or  veins.  It  is  characteristic  of  hemorrhoidal 
hemorrhages  that  the  blood  usually  appears  in  a  liquid, 
non-coagulated  state,  covering  the  fecal  matter,  but  not 
mixed  with  it.  If  the  hemorrhage  is  very  copious,  uncon- 
sciousness may  result  combined  with  symptoms  of  pro- 
found collapse.  This,  however,  happens  very  rarely.  Ac- 
companying the  local  manifestations,  especially  if  the  latter 
are  of  a  high  degree,  there  may  be  varied  general  symp- 
toms. Thus  dvspnoea,  palpitations  of  the  heart,  angina 
12 


178  DISEASES  OF  THE  INTESTINES. 

pectoris,  irregular  heart  action,  hiccough,  headaches,  gid- 
diness, dizziness,  buzzing  in  the  ears,  and  cloudy  vision 
may  be  present.  Often  a  despondent  feeling  and  a  condi- 
tion resembling  hypochondria  is  met  with.  Anorexia, 
nau&ea,  belching,  and  constipation  also  often  occur.  The 
general  symptoms  are  especially  marked  if  incarceration 
of  internal  piles  within  the  sphincter  has  taken  place.  In 
case  the  swelling  of  the  hemorrhoids  is  so  extensive  that 
a  reposition  cannot  be  quickly  effected,  there  may  be  pres- 
ent besides  the  local  i)ains  high  fever  and  signs  of  col- 
lapse. If  the  incarceration  lasts  a  long  period,  the  hem- 
orrhoids may  become  gangrenous  and  either  fall  off, 
accompanied  by  profuse  hemorrhage,  or,  although  rarely, 
give  rise  to  sejitic  and  peritonitic  conditions.  In  most 
instances  after  a  falling  off  of  the  hemorrhoid  a  sponta- 
neous cure  takes  place. 

Some  cases  of  hemorrhoids  are  complicated  with  catarrn 
of  the  rectum  (proctitis).  In  such  instances  the  stools 
reveal  the  presence  of  a  considerable  quantity  of  mucus, 
occasionally  even  of  pus..  Sometimes  the  mucous  or  mu- 
co-purulent  fluid  admixed  with  the  fseces  may  be  tinged 
with  blood.  These  cases  are  often  accompanied  by  a 
paretic  condition  of  the  sphincters,  which  allow  the  secre- 
tion to  dribble  from  the  anus.  This  gives  rise  to  excoria- 
tions and  inflammation  of  the  anus  and  the  neighboring 
tissues.  In  the  course  of  the  proctitis  prolonged  tenesmus 
may  appear  at  times.  If  the  inflammation  extends  into  the 
rectal  cellular  tissue,  it  may  lead  to  the  formation  of  ab- 
scesses which  may  empty  into  or  outside  the  bowels.  This 
is  the  most  frequent  way  in  which  fistulfe  are  produced. 

Disturbances  of  the  adjacent  organs  are  also  occasion- 
ally met  with  in  cases  of  piles.  Thus  ischuria,  stranguria, 
hemorrhages  from  the  bladder,  hemoiThages  from  the  va- 


HEMORRHOIDS.  179 

giua,  and  catarrhal  conditions  of  the  latter  are  encoun- 
tered. 

Diagnosis. — The  diagnosis  of  hemorrhoids  as  a  rule  is 
easy.  External  piles  are  found  by  inspection  of  the  anus, 
the  patient  lying  on  his  side  with  the  thighs  drawn  up. 
The  buttocks  are  pushed  aside  with  the  hands,  and  the 
patient  is  instructed  to  strain  in  a  similar  manner  as  when 
having  a  stool.  Nodules  of  a  reddish-bluish  tinge  will  be 
noticed  in  the  immediate  vicinity  of  the  anus  or  partly 
within  it.  It  is  characteristic  of  hemorrhoidal  nodules 
to  increase  in  size  during  a  period  of  constipation,  and  to 
diminish  after  an  efficient  evacuation  of  the  bowels. 

Condylomata  and  small  skin  tags  around  the  anus  can  be 
easily  differentiated  from  piles.  Condylomata,  as  a  rule, 
encircle  the  anus  and  are  present  also  on  other  parts  of  the 
body,  especially  on  the  scrotum.  Besides,  there  will  be 
a  previous  history  of  syphilis,  and  occasionally  other  lue- 
tic manifestations.  The  cutaneous  tags  present  more  the 
appearance  of  whitish-looking  skin,  never  change  in  size, 
and  do  not  bleed  when  jjunctured,  while  hemorrhoids 
bleed  profusely  on  puncture. 

The  diagnosis  of  internal  hemorrhoids  can  be  made  by  a 
digital  examination  or  by  this  in  connection  with  the  in- 
spection of  the  lower  portion  of  the  rectum  by  means  of  a 
speculum.  The  characteristics  of  internal  piles  are  similar 
to  those  of  external  hemorrhoids.  Thej'  can  be  easily 
differentiated  from  polypi  by  means  of  puncture  with  the 
needle.  Polypi  do  not  bleed  when  punctured.  Besides, 
polypi  are  usually  found  in  children,  while  hemorrhoids 
occur  with  greatest  frequency  in  the  advanced  period  of 
life. 

Carcinoma  of  the  rectum  will  rarely  give  rise  to  mistakes, 
the  tumor  usually  presenting  a  much  harder  consist<^ncy 


180  DISEASES  OF  THE  INTESTINES. 

than  hemorrhoids.  As  a  rule,  there  will  also  be  other 
signs  of  a  malignant  trouble,  cachexia,  etc.  It  is  needless 
to  say  that  cancer  of  the  rectum  may  be  combined  with 
hemorrhoids.  As  a  matter  of  fact,  it  very  often  gives  rise 
to  their  development,  and  the  discovery  of  piles  which 
have  formed  within  a  short  i)eriod  of  time  should  indeed 
rouse  the  suspicion  of  cancer  of  the  rectum. 

Ptogiiosis.  — The  prognosis  of  external  as  well  as  internal 
piles  is  as  a  rule  favorable.  They  generally'  exist  for  a 
long  time,  not  infrequently  throughout  life.  They  hardly 
ever  endanger  life,  unless  some  grave  complications  (incar- 
ceration of  the  hemorrhoids  or  gangrenous  processes  or 
very  profuse  hemorrhages)  supervene.  Hemorrhoids  are 
liable  to  recede  or  even  to  disappear  entirely,  especially  if 
the  factors  producing  them  have  been  eliminated. 

Treatment. — A  rational  mode  of  living  is  of  the  greatest 
importance.  Patients  with  hemorrhoids  should  have 
plenty  of  outdoor  exercise,  should  partake  of  food  with 
moderation,  should  avoid  all  excesses  in  baccho  and  in 
venere,  and  should  endeavor  to  have  a  daily  evacuation  of 
the  bowels.  Any  condition  causing  venous  hyiJersemia  of 
the  rectum  must  be  removed.  Thus  vocations  requiring 
constant  sitting,  or  constant  standing,  or  horseback  riding 
should  be  entirely  or  partly  given  up. 

With  regard  to  diet  the  following  general  rules  may  be 
given:  Patients  with  hemorrhoids  should  avoid  copious 
meals.  They  should  rather  eat  often  and  s  pariugly .  Fish, 
fresh,  well-cooked  vegetables,  and  rii)e  fruit  should  form  a 
considerable  part  of  their  diet.  Alcoholic  beverages,  strong 
coffee,  and  highly  seasoned  dishes  should  be  avoided.  The 
different  kinds  of  cheese,  very  coarse  brown  bread,  cabbage, 
peas,  and  beans  are  best  eliminated  from  the  diet.  Salads, 
potatoes,  beets,  spinach,  asparagus,  cauliflower,  are,  how- 


HEMORRHOIDS.  181 

ever,  rather  of  benefit  if  taken  in  small  quantities,  as  these 
articles  make  the  intestinal  contents  more  liquid.  Stewed 
fruits  and  also  raw  fruit,  as  for  instance  apples,  pears, 
prunes,  oranges,  grapes,  are  useful.  As  a  beverage,  plain 
water,  best  taken  between  meals  in  the  quantity'  of  a  pint, 
is  most  beneficial.  In  some  instances,  especially  in  anae- 
mic patients,  buttermilk  in  the  same  quantity  may  be 
taken  instead  of  water.  A  small  amount  of  light  beer  is 
permissible  in  some  cases. 

With  reference  to  hygiene  or  prophylactic  measures  it 
is  of  importance  for  the  patients  to  have  plenty  of  outdoor 
exercise,  especially  walking.  The  exercise,  however,  should 
not  be  continued  to  over-fatigue.  Gymnastic  exercises  at 
home,  sawing  or  chopping  wood,  and  the  like,  and  also 
massage  are  best  adapted  for  this  purpose.  The  patients 
should  wash  the  affected  part  in  the  morning  and  evening 
with  cool  water.  They  should  sit  on  caned  chairs,  not  on 
upholstered  ones,  and  should  sleep  on  a  mattress. 

The  patient  should  have  a  good  evacuation  of  the  bowels 
daily.  In  case  this  does  not  occur,  it  will  be  of  the  great- 
est importance  to  secure  it  by  the  different  therapeutic 
measures  at  our  disposal  (see  Chapter  X.,  on  constipa- 
tion). As  a  rule,  however,  powerful  laxative  and  drastic 
remedies  should  be  avoided.  The  frequent  use  of  injec- 
tions had  also  best  be  omitted.  The  purgatives  most 
adapted  for  these  patients  are  the  saline  ones,  sulphur  and 
rhubarb  drugs.  Thus  compound  licorice  powder,  a  tea- 
spoonful  in  the  evening,  or  sulph.  depur.,  potas.  bitartrat. 
aa,  also  one  teaspoonful  in  the  evening.  Rhubarb  in  the 
form  of  tincture  or  in  substance  0.6  to  1  gm.,  taken  once 
or  twice  daily,  is  also  advantageous  for  a  prolonged  use. 
The  waters  of  Carlsbad,  Kissingen,  Marienbad,  Tarasp, 
Saratoga,  will  also  be  of  benefit,  especially  if  taken  at  the 


182  DISEASES  OF  THE  INTESTINES. 

watering-places  themselves  in  connection  with  a  prescribed 
diet.  If  the  hemorrhoids  have  already  attained  consider- 
able size,  local  remedies  will  often  be  required. 

Local  Treatment. — The  irritation  or  the  rubbing  of  the 
piles  against  each  other  or  against  the  skin  must  be  pre- 
vented. For  this  purpose  covering  the  piles  with  a  small 
piece  of  smooth  and  clean  cotton  is  of  benefit ;  still  better, 
however,  for  this  purpose  is  cotton  moistened  in  olive  oil 
or  covered  with  vaseline  or  a  soft  salve  (Hebra's  ointment 
or  ointments  of  zinc,  lead,  boracic  acid) .  If  the  piles  are 
inflamed,  it  is  best  to  first  paint  them  a  few  times  with  the 
following  solution : 

I^  Potas.  iodidi 2.0  (  3  ss. ) 

lodi  puri 0.2  (gr.  iiiss. ) 

Glycerin 40.0  (  3  x.) 

before  applying  the  ointment.  After  a  movement  the  anus 
and  the  piles  should  be  first  washed  with  cool  water  and 
then  wiped  off  with  soft  cotton  or  linen.  This  must  be 
done  very  gently.  Persons  suffering  with  annoying  tenes- 
mus after  defecation  should  accustom  themselves  to  go  to 
stool  before  retiring.  The  recumbent  position  which  the 
patients  are  thus  able  to  assume  soon  after  the  passage 
affords  them  decided  relief. 

If  there  are  pains  in  the  rectum  caused  by  a  mere  hyper- 
aesthesia  of  the  mucous  membrane,  an  injection  of  one  to 
two  teaspoonfuis  of  warm  olive  oil  or  of  the  same  quantity 
of  warm  water  into  the  bowel  will  exert  a  favorable  influ- 
ence. If  this  fails,  or  in  cases  in  which  the  pains  are 
caused  by  a  superficial  excoriation  of  the  piles,  it  is  best 
to  apply  an  ointment  containing  some  narcotic  after  an 
evacuation  of  the  bowels,  and  sometimes  even  during  the 
intervals.  The  following  salve,  recommended  by  Rosen- 
heim, is  very  appropriate : 


f 

HEMORRHOIDS.  183 

I^  Lanolin 20.0  (  3  v. ) 

Bism.  subnitr 2.0  {  3  ss.) 

Extr.  opii 0.3  (gr.  v. ) 

M.  f.  ungt. 

In  place  of  the  ointment  the  piles  may  be  painted  with  a 
solution  containing  equal  parts  of  fluid  extracts  of  opium 
and  belladonna,  or  with  a  two-per-cent  cocaine  solution. 
Suppositories  containing  opium,  belladonna,  or  cocaine 
are  also  effectual. 

Internal  piles  prolapsing  through  the  anus  should  be 
pushed  back  by  the  patient  after  anointing  them  with  olive 
oil  or  with  vaseline.  In  case  the  reposition  is  not  easy, 
painting  of  the  piles  with  a  two-per-cent  cocaine  solution 
will  after  a  while  lessen  the  sensitiveness  and  thus  make  re- 
position possible.  In  some  obstinate  cases  the  patient  must 
be  narcotized  in  order  to  accomplish  this.  If  the  incarcerat- 
ed piles  have  already  become  gangrenous,  the  pains  usually 
grow  less.  In  order  to  arrest  the  necrotic  process  it  is 
advisable  to  dust  the  affected  area  with  an  antiseptic  powder 
(dermatol)  and  to  cover  it  with  dry  gauze.  The  pile  usu- 
ally falls  off  spontaneously  and  the  wound  heals  of  itself. 

The  inflammatory  processes  in  piles  require  special 
treatment  in  the  stage  of  exacerbation  (general  antiphlo- 
gistic remedies) .  Thus  rest  in  bed  on  the  side,  applica- 
tion of  cold  in  the  form  of  an  icebag  or  a  Priessnitz  poultice, 
occasionall}^'  leeches  in  the  neighborhood  of  the  anus,  not 
on  the  piles  themselves.  Application  of  cold  lead  water  is 
also  useful.  lu  case  there  are  signs  pointing  to  the  forma- 
tion of  pus  or  the  development  of  a  septic  process,  surgical 
inters'ention  is  imperative.  An  incision  into  the  hardened 
piles  followed  by  thorough  extirpation  is  essential.  Inas- 
much as  such  an  operation  must  be  done  under  chloroform 
narcosis,  the  radical  removal  of  the  entire  hemorrhoidal 
area  is  therefore  best  performed  at  the  same  time. 


f 
184  DISEASES  OF  THE  INTESTINES. 

Hemorrhoidal  hemorrhages,  if  not  extensive,  and  if  occur- 
ring at  long  intervals,  will  hardly  require  any  therapeutic 
measures.  If,  however,  the  quantity  of  blood  is  quite  con- 
siderable or  if  the  hemorrhage  is  protracted,  the  following 
means  should  be  employed :  An  icebag  should  be  applied 
to  the  anus  for  several  hours,  or  in  case  the  hemorrhage 
results  from  internal  piles,  a  cylindrical  piece  of  ice  is 
pushed  up  into  the  anus  and  replaced  every  half-hour. 
The  rectal  refrigerator  may  likewise  be  used  with  benefit. 
Very  cold  injections  are  also  useful.  In  cases  with  very 
frecjuent  hemorrhages  injections  of  water,  to  which  an  as- 
tringent remedy  has  been  added,  are  beneficial.  Thus  a 
two-per-cent  solution  of  tannic  acid  or  of  alum,  or  a  0.3- 
per-cent  solution  of  acetate  of  lead  may  be  applied.  The 
following  ointment,  first  suggested  by  Kossobudskj,'  may 
also  be  applied  in  these  cases : 

^  Chrysarobin 0.8  (gr.  xiij.) 

Iodoform 0. 3  (gr.  v.) 

Extr.  bellad 0.6  (gr.  x.) 

Vaselini 15.0  (|  ss.) 

M.  f.  ungt. 

This  salve  not  only  checks  the  hemorrhage,  but  has  also 
an  excellent  effect  in  reducing  the  size  of  the  pile.  In  in- 
ternal hemorrhoids  the  following  suppository  ,may  be  used 
for  the  same  purpose : 

^  CJhrysarobin 0.1  (gr.  if) 

Acidi  tannic! 0. 1  (gr.  i}) 

Iodoform ." 0.2  (gr.  iiii) 

Extr.  opii 0.03  (gr.  i) 

01.  theobrom 2,0  (3  ss.) 

M.  f.  Suppository.     S.  One  suppository  in  the  evening. 

'  Kossobudskj :  Centralblatt  fQr  Chirurgie.  1889. 


HEMORRHOIDS.  186 

Radical  Treatment. — 1.  Dilatationof  the  Sphincters.  Ver- 
neuil '  was  the  first  to  recommend  dilatation  of  the  sphinc- 
ters as  a  cure  for  piles.  This  treatment  is  based  upon  the 
idea  that  the  spasm  of  the  sphincter  is  thereby  stopped, 
that  the  bowels  act  more  freely  and  the  pressure  upon  the 
venous  blood-vessels  is  relieved.  The  dilatation  of  the 
sphincters  may  be  accomplished  gradually  by  introducing, 
specula  into  the  rectum,  taking'  a  larger  size  each  time, 
which  proce.dure  occupies  several  weeks,  or  it  may  be  done 
in  one  sitting  (the  so-called  forcible  dilatation).  In  the 
latter  instance,  however,  chloroform  narcosis  is  necessary. 
Complete  dilatation  is  effected,  according  to  Allingham,  in 
the  following  way  :  The  patient  being  fully  under  the  influ- 
ence of  ether  or  chloroform,  both  thumbs  must  be  inserted 
into  the  rectum,  which  is  to  be  dilated  gradually,  first  in 
the  antero-posterior  and  afterward  in  the  opposite  direc- 
tion. The  amount  of  force  used  must  be  sufficient  to  over- 
come the  spasm  thoroughly.  This  manipulation  must  be 
continued  until  the  sphincter  muscles  yield,  as  if  reduced 
to  a  really  pulpy  condition.  Care  must  be  taken  to  act 
high  enough  up  in  the  rectum  so  as  to  include  the  whole 
of  the  sphincter.  The  result  is  that  the  state  of  contrac- 
tion is  abolished  and  no  s})asm  can  occur.  In  fact,  for  the 
time  being,  as  in  any  other  stretched  muscle,  paralysis  re- 
sults. With  great  gentleness  the  desired  effect  may  be  ac- 
complished without  tearing  the  mucous  membrane.  But 
some  extravasation  is  usually  noted  around  the  anus  for  a 
few  days.  After  this  an  opium  suppository  is  kept  in  the 
rectum  and  the  patient  is  placed  in  bed  in  a  recumbent 
position.  Dilatation  of  the  sphincters  may  be  recom- 
mended in  the  early  stage  of  hemorrhoids,  especially  in 
cases  combined  with  constipation ;  further  in  hemorrhoids 
'  Verneuil :  Gazette  des  hop.,  1884,  1887. 


186  DISEASES  OF  THE  INTESTINES. 

during  pregnancy  or  occurring  in  persons  greatly  debili- 
tated by  other  grave  diseases. 

2.  Cai'bolic-Acid  Injections.  Pooley , '  Kelsey , '  Roux, '  and 
Lange  *  have  recommended  injections  of  carbolic  acid  into 
the  piles  in  order  to  produce  shrinking.  This  method  is  per- 
missible only  if  the  hemorrhoids  are  not  inflamed.  Proceed 
as  follows:  The  piles  are  first  thoroughly  cleansed  and 
dried,  then  covered  with  iodoform  salve.  In  order  to 
lessen  the  pains  a  few  drops  of  a  one-per-cent  cocaine  so- 
lution may  first  be  used  subcutaneously.  Then  three  to 
five  drops  of  either  of  the  two  following  solutions  are  in- 
jected into  the  centre  of  each  pile:  (1)  Carbolic  acidl,  gly- 
cerin 3;  (2)  Carbolic  acid  1,  glycerin  3,  distilled  water  3. 
The  injection  is  made  with  the  common  Pravaz  syringe, 
but  care  must  be  taken  that  none  of  the  solution  drips  from 
the  needle,  so  as  to  avoid  cauterizing  the  mucous  mem- 
brane. Several  piles  can  be  treated  at  the  same  sitting. 
It  is  advisable,  however,  not  to  make  the  injections  ofteuer 
than  about  once  a  week.  This  procedure  if  carefully  done 
is  not  dangerous  nor  painful,  and  often  effects  shrinking 
or  even  disappearance  of  quite  considerable  hemorrhoidal 
nodules. 

3.  Cauierizatimi  luith  Fuming  Nibic  Acid.  Houston,"  of 
Dublin,  was  the  first  to  recommend  cauterization  of  piles 
with  fuming  nitric  acid.  This  may  be  done  in  the  follow- 
ing manner :  After  thorough  cleansing  and  drying  of  the 
anus  and  the  surrounding  parts,  the  entire  area  is  covered 

'  J.  H.  Pooley  :  "  Injection  of  Carbolic  Acid  in  Hemorrhoids. "  To- 
ledo Med.  and  Surg.  Journal,  November,  1877,  No.  11. 

'  Charles  B.  Kelsej- :  "  The  Treatment  of  Hemorrhoids.  "  Medical 
Record,  1886,  vol.  ii.,  p.  141. 

'Roux:  "Behandlung  der  Hamorrhoiden."  Therap.  Monatshefte, 
1895,  p.  124. 

■•  F.  Lange  :  Centralblatt  fur  Chirurgie,  1887,  No.  25.  Beilage,  p.  70. 

*  Houston  :  Dublin  Jourual  of  Medicine,  1844. 


HEMORRHOIDS.  187 

with  a  thick  layer  of  vaseline  excepting  the  pile  which  is 
to  be  treated.  The  latter  is  then  painted  with  nitric  acid 
by  means  of  a  small  stick  of  wood  or  a  glass  rod.  Special 
care  must  be  taken  that  the  acid  reaches  no  other  spot. 
After  the  nodule  has  assumed  a  grayish-green  color  it  is 
carefully  dried,  smeared  with  vaseline,  and  pushed  back 
into  the  rectum.  This  method  is  best  adapted  for  smaller 
nodules,  especially  if  they  have  a  wide  base.  Sometimes 
a  second  cauterization  is  necessary,  which  may  be  done 
after  an  interval  of  about  five  days  or  a  week.  Instead  of 
nitric  acid  other  cauterizing  substances  may  be  used,  and 
Allingham  has  recommended  concentrated  carbolic  acid  as 
especially  efficient  for  this  purpose. 

4.  Ligature.  Cooper '  recommended  the  ligature  of  hem- 
orrhoids in  order  to  cut  them  off  from  the  circulation  and 
thus  destroy  them.  Salmon^  has  imj)roved  this  method 
by  making  an  incision  before  applying  the  ligature.  Ac- 
cording to  this  writer,  the  operation  is  performed  in  the 
following  manner :  The  patient  is  placed  on  the  right  side 
on  a.  hard  couch  and  is  completely  anaBsthetized.  The 
sphincter  muscles  are  then  gently  but  completely  dilated. 
The  hemorrhoids,  one  by  one,  are  then  drawn  down  with  a 
pronged  hook  fork ;  by  means  of  sharp  scissors  the  pile  is 
separated  from  its  connections  with  the  muscular  and  sub- 
mucous tissues  upon  which  it  rests.  The  cut  is  best  made 
in  the  sulcus  or  white  mark  which  is  seen  where  the  skin 
meets  the  mucous  membrane.  This  incision  is  made  in  a 
direction  parallel  to  the  bowel  and  carried  to  such  a  dis- 
tance that  the  pile  is  left  connected  by  an  isthmus  of  vessels 
and  mucous  membrane  only.  A  well-waxed,  strong,  thin, 
aseptic  silk  ligature  is  now  placed  at  the  bottom  of  the  deep 

'  Cited  from  Alliugham,  loc.  cit. 
« Ibid. 


188  DISEASES  OF  THE  INTESTINES. 

groove  which  has  been  made,  and  the  ligature  is  tied  right 
at  the  neck  of  the  tumor  as  tightly  as  possible.  When  all 
the  hemorrhoids  have  thus  been  ligated,  they  should  be 
returned  within  the  sphincter.  A  small  piece  of  absor- 
bent cotton  saturated  with  iodoform  ointment  is  now 
placed  into  the  bowel  and  a  pad  of  cotton  applied  over  the 
anus. 

5.  Crushing.  Crushing  of  piles  has  been  suggested  by 
Pollock  and  the  method  further  improved  by  Allingham,' 
who  devised  a  very  ingenious  apparatus  for  this  purpose, 
namely,  the  "screw-crushing  instrument."  The  operation 
begins  with  the  dilatation  of  the  sphincters.  The  hemor- 
rhoid is  then  drawn  into  the  screw-crusher  by  means  of  a 
hook,  and  this  being  intrusted  to  an  assistant  the  bar  is 
pushed  up  and  screwed  home  as  tighth'  as  possible.  The 
pile  should  be  crushed  longitudinally  and  not  transversely. 
The  projecting  portion  of  the  pile  is  cut  oflF  with  the  knife 
or  scissors  and  the  pressure  kept  up  for  about  one  minute. 
According  to  Allingham  crushing  is  a  very  satisfactory 
method  of  removing  internal  piles. 

6.  Thermo-cautery  (Paquelin)  and  Galvano-cautery.  Lan- 
genbeck  introduced  the  method  of  operating  upon  piles 
by  means  of  thermo-cautery.  Each  pile  is  seized  with  a 
volsellum  forceps  and  drawn  well  down.  The  clamp  is 
then  applied  so  as  to  embrace  its  base.  The  portion  above 
the  clamp  is  cut  off  with  a  pair  of  scissors  and  the  cautery- 
iron,  heated  to  a  dull  red  heat,  is  rejjeatedly  applied  to  the 
stump  until  all  the  vessels  are  well  seared. 

Instead  of  using  the  Paquelin,  galvano-cautery  may  be 
applied  for  the  removal  of  hemorrhoids,  the  technique 
being  identical  with  the  former.  Bardeleben  and  also  Ro- 
senheim strongly  recommend  the  latter  method. 

'  Allingham  :  "Diseases  of  the  Rectum. "  1896,  p.  153. 


HEMORRHOIDS.  189 

7.  Extirpation  of  HemoiThoids,  followed  by  Suture.  This 
method  was  first  introduced  by  von  Esmarch '  in  Germany 
and  by  Whitehead  in  England.  It  is  not,  however,  exten- 
sively used  as  it  is  (juite  complicated,  besides  giving  rise  to 
many  disagreeable  comijlications.  Thus  Allingham  has 
noticed  the  following  sequels  of  such  an  operation :  1.  Anal 
stricture.  2.  Loss  of  sensation  and  control  over  the 
anus.  3.  Irritation  of  the  mucous  membrane  due  to  fre- 
quent discharges  of  mucus  and  at  times  accompanied  by 
bleeding. 

After  any  of  the  above-named  operations  it  was  customary 
to  emjiloy  an  astringent  in  order  to  prevent  a  movement 
of  the  bowels  for  a  few  days.  Contrary  to  this  method  E. 
Graser  "^  is  of  the  opinion  that  such  patients  are  better  oflf 
when  having  a  free  movement  shortly  after  the  operation. 
He  administers  soon  after  its  performance  a  small  dose  of 
castor  oil  and  instructs  the  patient  to  have  an  evacuation 
while  in  a  warm  sitz  bath.  Cleansing  of  the  anus  is  very 
easily  obtained  in  this  manner.  After  an  antiseptic  wash- 
ing a  piece  of  cotton  or  linen,  thickly  smeared  with  an 
ointment,  is  introduced  into  the  rectum.  This  procedure 
has  usually  to  be  performed  once  daily.  According  to 
Graser,  the  patients  if  thus  treated  are  almost  without  pain, 
and  are  able  to  get  up  and  be  out  of  bed  five  or  seven 
days  after  the  operation.  For  some  time  after  its  perform- 
ance it  is  advisable  to  have  the  patient  introduce  bougies 
of  varying  size  into  the  rectum  in  order  to  prevent  the  for- 
mation of  a  stricture. 

Complications. — Prolapse  of  the  Rectum.  Prolapse  of  the 
rectum  is  a  frequent  complication  of  hemorrhoids,  although 

'von  Esmarch:  "Die  Kraukheiten  des  Mastdarnis  und  Afters," 
Stuttgart,  1887. 

■^  E.  Graser  :  Penzoldt  u.  Stinzing,  *'  Handbuch  d.  Theraple,  "  Bd.  iv., 
p.  634. 


190  DISEASES  OP  THE  INTESTINES. 

it  may  also  occur  alone.  The  prolapse  may  involve  either 
the  mucous  membrane  alone  or  all  the  coats  of  the  rectum. 
In  the  latter  instance  this  condition  is  also  called  proci- 
dentia recti.  Outside  of  the  anus  there  is  a  protrusion  of 
the  mucous  membrane  in  its  entire  circumference.  An 
internal  prolapse  of  the  rectum  may  also  occur,  which  con- 
sists in  the  descent  of  the  upper  part  of  the  rectum  through 
the  lower  part,  but  not  appearing  outside  the  anus.  This 
corresponds  rather  to  an  intussusception.  A  relaxation  of 
the  ligaments  which  serve  to  keep  the  rectum  in  its  place 
is  often  the  cause  of  this  malady.  Weakness  and  paralysis 
of  the  sphincter  ani  muscles  are  also  predisposing  factors. 

Prolapse  of  the  rectum  is  fre(iuently  found  in  debilitated 
children,  especially  if  an  intestinal  catarrh  is  present,  for 
these  little  patients  go  to  stool  too  often  and  usually  strain 
too  much  and  for  too  long  a  time.  These  conditions  weaken 
the  muscular  apparatus  of  the  anus,  and  thus  a  prolapse  of 
the  rectum  easily  arises.  In  elderly  people,  in  patients 
suffering  from  affections  of  the  bladder  or  from  severe 
constipation  and  internal  hemorrhoids,  and  in  women 
who  have  gone  through  many  pregnancies  in  quick  suc- 
cession, prolapse  of  the  rectum  is  also  a  frequent  oc- 
currence. 

The  symptoms  are  as  follows :  If  the  ])rolapae  is  only  of 
a  moderate  degree,  there  appears  in  the  act  of  defecation  a 
protrusion  of  the  rectum  outside  the  anus,  one  or  one  and 
a  half  inches  in  length,  the  mucosa  looking  quite  red  and 
puckered.  In  the  more  advanced  stage  the  bulged  out 
rectum  resembles  a  large  tumor  with  a  star-like  opening 
at  its  centre,  while  the  color  is  pale  or  bluish-red.  In 
children  the  mass  generally  protrudes  only  ou  going  to 
stool,  but  in  adults  it  is  constantly  down'  or  comes  down 
on  the  slightest  exertion,  and  therefore  may  become  ulcer- 


HEMORRHOIDS.  191 

ated  or  inflamed.  In  old  cases  of  prolapse  incontiiieiic& 
of  fasces  is  also  frequently  present. 

The  diagnosis  of  prolapse  of  the  rectum  is  easily  made 
from  the  above-mentioned  appearances.  Internal  prolapse 
is  net  so  easily  diagnosed,  as  the  mass  never  appears  out- 
side the  anus.  This  condition  can  be  recognized  only  by 
means  of  a  digital  examination  of  the  rectum.  The  finger 
introduced  into  the  bowel  is  first  kept  close  to  the  anterior  or 
posterior  wall,  and  is  passed  up  until  it  meets  with  an  ob- 
struction (i.e.,  it  has  passed  into  the  cul-de-sac).  Then 
the  finger  is  slightly  withdrawn  and  the  centre  of  the  gut 
examined  until  an  orifice  is  found  into  which  the  finger  or 
a  bougie  niaj^  be  passed  for  some  inches  high  up  into  the 
rectum.  If  the  intussusception  is  rather  far  up  in  the  rec- 
tum, the  patient  should  bear  down  during  the  examination. 

With  regard  to  treatment  it  is  of  importance  to  eliminate 
all  the  conditions  which  were  predisposing  factors  for  the 
prolapse.  Extreme  cleanliness,  especially  after  defecation, 
should  be  observed.  The  reposition  of  the  prolapse  should, 
be  performed  in  the  most  careful  manner.  It  is  best  done 
in  the  knee-elbow  posture.  If  a  considerable  portion  of 
the  bowel  has  come  down,  a  large  flexible  bougie  may  be 
passed  into  the  bowel  in  such  a  manner  as  to  carry  before 
it  the  upper  part  of  the  descended  gut.  General  taxis 
should  at  the  same  time  be  used,  and  in  this  way  the  mass 
can  generally  be  returned.  In  cases  in  which  the  prolapse 
occurs  quite  frequently,  even  during  a  walk,  a  rectal  sup- 
porter, as  suggested  by  von  Es march,  should  be  worn  by 
the  patient.  It  consists  of  a  soft-rubber  ball  Attached  to 
the  anus  by  means  of  a  belt  and  a  T  bandage. 

The  palliative  treatment  which  is  especially  successful  in 
children  is  as  follows :  All  sources  of  irritation  should  be  re- 
moved and  tho  general  health  strengthened.    Straining  at 


192  DISEASES  OF  THE  INTESTINES. 

stool  should  be  strongly  forbidden  and  a  mild  laxative 
remedy  given.  After  a  movement  of  the  bowels  the  pro- 
truded part  should  be  well  washed  with  cold  water  and 
pushed  back  into  the  anus  by  gentle  pressure.  After  this 
procedure  the  patient  should  remain  in  a  recumbent  position 
for  half  an  hour  or  so,  best  lying  on  the  abdomen.  If  these 
means  alone  are  not  sufficient,  the  following  more  radical 
measures  will  have  to  be  adopted :  Cauterization  of  the  pro- 
lapsed part  with  fuming  nitric  acid  or  with  the  thermo-cau- 
tery  under  chloroform  narcosis  is  often  of  great  benefit. 
Care  should  be  taken  while  cauterizing  not  to  touch  the 
verge  of  the  anus  or  the  skin.  After  this  the  prolapsed 
part  should  be  well  oiled  and  returned.  Instead  of  nitric 
acid  Allingham  uses  the  acid  nitrate  of  mercury. 

These  cauterizing  methods  have  the  disadvantage  of  often 
producing  strictures  of  the  rectum.  For  this  reason  a  num- 
ber of  surgical  operations  have  been  devised.  Thus  exci- 
sion of  triangular  or  elliptical  portions  of  the  mucous  mem- 
brane, bringing  the  edges  together  with  sutures,  has  been 
practised.  Extiri)ation  of  the  entire  prolapsed  portion  was 
first  advocated  by  Treves.'  F.  Lange,"  of  New  York,  has 
described  a  new  operation,  serving  the  purpose  of  reduc- 
ing the  calibre  of  the  rectum  and  at  the  same  time  produc- 
ing a  narrow  muscular  ring.  The  patient  is  placed  in  the 
genu-pectoral  position,  an  incision  is  made  from  the  lower 
part  of  the  sacrum  down  to  the  anus,  until  the  posterior 
wall  of  the  rectum  is  reached;  the  coccyx  is  then  removed. 
The  object  in  view  is  to  narrow  the  gut  as  high  as  jjossible 
and  to  lessen  the  impediments  to  the  action  of  the  levator 
ani.  The  calibre  of  the  rectum  is  lessened  by  introducing 
buried  etage  sutures  of  iodoformed  catgut,  which  do  not 

'  Treves :  Lancet.  1890,  vol.  1. 

*  F.  Lange  :  Annals  of  Surgery,  vol.  v.,  p.  497. 


HEMORRHOIDS.  193 

perforate  the  entire  thickness  of  the  gut.  The  first  rows 
are  inserted  near  the  middle  line  and  form  a  fold  in  the 
posterior  walls  which  protrudes  into  the  bowel.  In  this 
manner  the  more  lateral  portions  of  the  gut  are  brought 
into  position  without  causing  too  much  tension.  Similar 
sutures  are  applied  to  unite  the  cut  surfaces  of  the  levator 
ani  and  sphincter  externus,  which  had  been  previously  dis- 
sected in  order  to  lay  bare  the  posterior  wall  of  the  rectum. 
The  cavity  thus  formed  is  filled  up  with  iodoform  gauze 
and  the  flaps  of  integument  are  united  with  sutures. 

Another  very  efficient  operation  has  been  suggested  by 
AUingham  and  consists  in  making  a  small  incision  through 
the  anterior  abdominal  wall  on  the  left  side,  just  above  the 
outer  third  of  Poupart's  ligament,  then  introducing  the 
fingers  into  the  abdomen,  catching  hold  of  the  rectum  and 
pulling  it  up.  After  it  has  been  drawn  as  high  up  as  pos- 
sible, silk  threads  are  passed  through  the  mesentery  and 
the  latter  is  fastened  to  the  abdominal  wall. 

Fissure  of  the  Anas.  Another  affection  which  very  fre- 
quently occurs  in  connection  with  hemorrhoids  is  anal  fis- 
sure. The  latter  consists  of  an  oblong  tear  of  the  mucosa 
of  the  anus  and  gives  rise  to  severe  pain  and  spasmodic 
contractions  of  the  sphincters.  Fissures  or  ulcers  of  the 
anus  vary  in  depth  and  size.  Some  are  mere  abrasions  of 
the  mucous  membrane,  others  are  quite  large  and  deep  so 
that  the  muscular  fibres  are  laid  bare.  The  edges  of  the 
fissure  may  be  in  a  healthy  state  or  they  may  be  inflamed, 
callous,  and  indurated.  Fissure  of  the  anus  is  usually 
caused  by  an  injurj^  or  tearing  of  the  mucous  membrane 
at  the  verge  of  the  anus.  This  may  result  either  from  ex- 
cessive straining  or  from  the  passage  of  very  dry  hard 
scybala.     The  affection  is  more  often  found  in  women  than 

in  men.     The  posterior  portion  of  the  anus  is  the  point  of 
13 


194  DISEASES  OF  THE  INTESTINES. 

predilection,  although  the  fissure  may  occur  at  any  other 
place.  It  is  usually  situated  parallel  to  the  external  sphinc- 
ter, although  in  some  instances  it  may  lie  higher  up,  par- 
allel to  the  internal  sphincter  or  even  above  it. 

The  symptoms  consist  in  intense  pains  in  the  rectum  on 
defecation,  sometimes  persisting  afterward.  The  pains  are 
often  of  a  very  excruciating  character.  The  size  of  the  fis- 
sure does  not  seem  to  be  of  so  much  importance  with  regard 
to  the  severity  of  the  pain  as  its  position.  A  small  crack 
situated  at  the  anal  orifice  over  the  external  sphincter  and 
involving  the  skin  causes  much  greater  pain  than  a  large 
ulcer  situated  higher  up  in  the  rectum.  There  may  also 
be  a  discharge  of  blood  and  pus. 

The  diagnosis  of  anal  fissure  is  made  by  the  symptoms 
just  mentioned  and  by  local  examinations.  The  patient 
Ij'ing  on  his  left  side  should  be  told  to  bear  down,  and  the 
anus  opened  with  forefinger  and  thumb  as  gently  as  pos- 
sible. An  elongated  club-shaped  ulcer  will  be  seen  within 
the  orifice.  Its  floor  may  be  very  red  and  inflamed,  or  if 
the  ulcer  is  of  long  standing,  of  a  grayish  color,  with  well- 
defined  and  hard  edges.  Often  the  introduction  of  the  fin- 
ger into  the  anus  is  so  painful  that  before  making  the  ex- 
amination a  suppository  containing  one  grain  of  cocaine 
has  to  be  applied.  Sometimes  even  this  procedure  is  in- 
sufficient, and  then  chloroform  anaesthesia  will  be  required. 
For  a  fissure  situated  higher  up  above  the  internal  sphinc- 
ter examination  with  the  speculum  will  have  to  be  made. 

Fissures  of  recent  origin  can  often  be  cured  without  any 
operation.  Rest  in  the  recumbent  position  should  be 
adopted  as  much  as  possible.  Mild  laxatives  are  to  be 
recommended,  but  no  drastic  remedies  employed.  If  the 
patient  can  manage  to  have  a  movement  at  night  time  be- 
fore retiring,  it  will  be  of  advantage.     Locally,  the  fissure 


HEMORRHOIDS.  195 

should  be  touched  off  and  on  with  a  ten-per-cent  solution 
of  cocaine  or  with  a  ten-per-cent  solution  of  nitrate  of  sil- 
ver. Still  better  is  the  application  of  the  following  salve 
recommended  by  Allingham : 

9  Hydrarg.  subchlor gr.  iv. 

Pulv.  opii gr.  i j. 

Extr.  bellad gr.  ij. 

Ung.  sambuci 3i. 

M.  f.  ung. 

If  these  palliative  remedies  are  not  sufficient,  a  free  incision 
through  the  fissure  should  be  made.  The  cut  should  be 
rather  deep  and  should  reach  the  sphincter  muscles. 


CHAPTER  VIII. 

APPENDICITIS. 

Synonyms:  Scolecoiditis ;  Perityphlitis;  Paratyphlitis; 
Appendicular  inflammation. 

Definition. — Inflammation  of  the  appendix,  characterized 
by  localized  pains,  commonly  fever  and  digestive  disturb- 
ances. 

General  Remarks. — The  inflammatory  lesions  involving 
the  right  iliac  region  were  formerly  designated  as  typhlitis 
(inflammation  of  the  caBCum  itself),  perityphlitis  (inflam- 
mation of  the  peritoneal  covering  of  the  caecum),  and  para- 
typhlitis (inflammation  of  the  retro-peritoneal  connective 
tissue  of  the  csBcum),  GrisoUe  '  was  the  first  to  maintain 
that  inflammation  of  the  caecum  could  hardly  give  rise  to 
such  grave  lesions  as  are  found  in  the  right  iliac  fossa,  for 
even  ulcerations  of  the  caecum  and  colon  do  not,  as  a  rule, 
show  any  tendency  to  extend  into  the  neighboring  connec- 
tive tissue.  He  ascribed  the  above  conditions  to  an  inflam- 
mation of  the  appendix,  which  organ  shows  a  tendency 
to  perforate  and  to  lead  to  abscesses  in  the  right  iliac  fossa 
as  verified  by  post-mortem  examinations.  The  possibility 
of  a  stercoral  typhlitis  (inflammation  of  the  caecum  as  the 
result  of  accumulated  fecal  matter)  which  was  formerly 
generally  accepted,  is  now  held  by  but  very  few  writers, 

'  Grisolle  :  "  Tumeurs  Phlegmoneuses  des  Fosses  Iliaques. "  Archives 
de  MMecine,  1839. 


APPENDICITIS.  197 

as  for  instance,  Lennander.'  Sahli/  Nothnagel,'  Fow- 
ler/ Sonnenburg/  and  others  deny  its  existence.  The 
teachings  of  GrisoUe  found  further  support  through  the 
brilliant  investigations  of  Reginald  Fitz*  of  Boston, 
Sands,'  McBurney,*  Weir,"  Bull,'"  and  Fowler  of  New 
York,  were  supplemented  by  the  observations  of  Sonnen- 
burg,  Sahli,  Rotter,"  Rdux,'^  Talamon,*^  and  others,  and 
are  now  generally  accepted. 

Etiology. — In  former  years  much  importance  was  at- 
tributed to  the  occurrence  of  foreign  bodies  like  cherry 
stones,  grape  seeds,  lemon  and  orange  pits,  date  kernels, 
fish  bones,  pins,  etc.,  within  the  appendix  as  causative  fac- 
tors of  the  inflammatory  suppurative  process.  According 
to  Fowler,  the  belief  that  the  disease  is  frequently  due  to 
the  engaging  of  foreign  bodies  in  the  cavity  of  the  organ  is 
based  to  a  large  extent  upon  purely  speculative  or  imagi- 
nary conditions  or  erroneous  observations.  In  a  very  large 
number  of  cases  of  this  disease  upon  which  he  operatec^ 
Fowler  found  but  in  two  instances  any  body  other  than 
soft  fecal  masses  which  could  be  considered  as  being  in 

}  Lennander  :  "  Ueber  Appendicitis,  "  Wien,  1895. 
''Sahli:  "Ueber  das  Wesen  und  die  Behandlung  der  Perityphliti- 
den.  "    Correspondenzbl.  f.  Schweizer  Aerzte,  Basel,  1892. 
^Nothnagel:  "Krankheiten  des  Darms,  "  Wien,  1898. 

*  George  R.  Fowler:  "A  Treatise  on  Appendicitis, "  Philadelphia, 
1894. 

» Sonnenburg  :  "  Pathologic  und  Therapie  der  Perityphlitis,  "  Leip- 
zig, 1895. 

*  Reginald  Fitz :  American  Journal  of  the  Medical  Sciences,  1886; 
and  New  York  Medical  Journal,  1888. 

1  Sands  :  New  York  Medical  Journal.  1888,  p.  197-205,  607. 

^  Charles  McBurney  :  Annals  of  Surgery,  1891 ;  Medical  Record,  1892. 

'Robert  F.  Weir  :  Medical  Record  and  Medical  News,  1887-1892. 

"W.  T.  Bull:  Medical  Record,  1894. 

"  Rotter  :  "Ueber  Perityphlitis,  "  Berlin,  1897. 

'■^  Roux  :  Revue  de  Medecine  de  la  Suisse  romande,  1890.  1891,  1892. 

"Talamon:  "Appendicite  et  Perityphlite,  "  Paris.  1892. 


198  DISEASES  OF  THE  INTESTINES. 

any  seuae  foreign.  The  fecal  concretions  within  the  ap- 
pendix are  now  looked  upon  as  of  no  importance  whatever 
with  regard  to  the  causation  of  the  disease,  as  they  are  also 
accidentally  encountered  in  perfectly  normal  appendices. 
The  opinion  generally  prevails  that  the  inflammation  is 
caused  by  micro-organisms  which  are  conveyed  to  the  in- 
terior of  the  organ  in  the  fecal  matter.  According  to 
Nothnagel,  however,  fecal  concretions  play  a  prominent 
part  in  lesions  leading  to  perforation  of  the  appendix. 

Movable  kidney  has  been  assumed  to  be  a  predisposing 
factor  in  the  development  of  appendicitis  by  Carl  Beck ' 
and  Edebohls.'  The  much  greater  frequency  of  movable 
kidney  in  the  female  and  the  comparative  infrequency  of 
appendicitis  in  the  latter  as  compared  with  the  male  sex 
seems  to  speak  somewhat  against  this  \iew. 

Actinomycosis,  tuberculous  and  typhoid  ulcers  are  pre- 
disposing causes  of  the  disease.  Occlusion  of  the  lumen  of 
the  appendix,  either  partial  or  complete,  is  likewise  a  pre- 
disposing factor.  These  occlusions  may  be  the  result  of 
former  inflammatory  lesions,  but  are  most  frequently  due 
to  the  retrograde  changes  which  this  organ  is  gradually 
undergoing  in  the  process  of  evolution.  According  to  Rib- 
bert^  and  Zuckerkandl,'  the  appendix  is  found  obliterated 
in  about  twenty-five  pei  cent  of  all  living  persons.  Both 
these  writers  ascribe  this  condition  not  to  inflammatory 
diseases,  but  to  the  progress  of  evolution  which  takes  place 
in  the  appendix.     This  view  is  supported  by  the  fact  that 

'Carl  Beck:  "Appendicitis."  Volkmann's  Samralung  kliniscber 
Vortrage.  No.  221.  Leipzig,  1898. 

«  George  M.  Edebohls  :  Medical  Record.  1898. 

'Ribbert:  "Beitriige  zur  normalen  und  patbologiscben  Anatomie 
des  Wurmfortsatzes.  "    Vircb.  Arcb.,  Bd.  132. 

*  E.  Zuckerkandl :  "  Ueber  die  Obliteration  des  Wurmfortsatzes  beim 
Menschen, "  Wiesbaden,  1894. 


APPENDICITIS.  199 

obliteration  of  the  appendix  is  found  with  gradually  in- 
creasing frequency  in  more  advanced  age.  Thus  Kibbert 
found  obliteration  of  the  appendix  in  fifty  per  cent  of  per- 
sons above  sixty  years  of  age. 

Why  the  appendix  should  be  the  seat  of  disease  so  very 
much  more  frequently  than  other  parts  of  the  intestine  is 
a  question  which  cannot  be  so  easily  answered.  The  fact 
that  the  appendix  is  a  rudimentary  organ  in  which  proc- 
esses of  evolution  are  even  normally  discoverable  makes  it 
probable  that  it  is  imbued  with  less  resistance  against  dis- 
ease-producing agents.  The  comparatively  nari'ow  lumen 
of  the  appendix  and  Gerlach's  valve  make  the  emptying  of 
this  little  canal  a  difficult  matter.  This,  in  connection  with 
the  scantiness  of  circular  muscular  fibres  in  the  walls  of 
the  appendix  explains  the  slowness  with  which  substances 
within  the  appendicular  cavity  are  emptied  into  the  intes- 
tine. Stagnation  of  contents  in  this  organ  is  certainly  a 
predisposing  factor  for  disease.  The  abundance  of  ade- 
noid tissue  in  the  appendix  has  been  believed  b3'  some 
writers  to  be  a  predisposing  cause  of  disease.  Bacterial 
infections  here  take  place  in  a  similar  manner  as  in  the 
tonsils,  and  Sahli  speaks  by  way  of  comparison  of  an  an-: 
gina  of  the  appendix.  Fowler  and  Van  Cott '  believe  that 
the  vascular  arrangement  of  the  appendix  (scantiness  of 
blood  supply,  the  main  vessels  being  almost  end  arteries) 
is  responsible  to  a  great  extent  for  the  frequency  of  dis- 
ease in  this  organ.  Some  of  the  blood-vessels  and  nerves 
are  primarily  affected,  and  the  nutrition  of  the  appendix 
being  thus  disturbed,  diseases  of  an  infective  character 
easily  take  place.  Another  predisposing  cause  of  appen- 
dicitis is  displacement  and  malformation  of  the  appendix. 

While  all  the  above-mentioned  factors  may  predispose 
>  Van  Cott'Fowler  :  "Treatise  on  Appendicitis." 


200  DISEASES  OP  THE  INTESTINES. 

the  appendix  to  disease,  the  real  cause  of  the  latter  must 
be  looked  for  in  a  bacterial  invasion.  Talamon  was  the 
first  to  lay  stress  upon  the  importance  of  microbes  in  ap- 
pendicitis. Nowadays  all  writers  coincide  with  this  view. 
Thus  Tavel,'  Hodenpyl,'  Fowler,  Wilson,' Barbacci/  and 
others  ascribe  a  very  important  i^art  to  the  bacillus  coli 
communis  (Escherich),  which  is  almost  always  encoun- 
tered in  lesions  of  the  appendix,  either  in  the  exudate,  pus, 
or  the  walls  of  the  appendix  itself.  Other  micro-organ- 
isms are,  however,  frequently  found  either  in  connection 
with  the  bacterium  coli  commune  or  alone.  Thus  strepto- 
coccus pyogenes,  pneumococcus,  staphylococcus  pyogenes 
aureus,  bacterium  lactis,  bacillus  pyocyaneus  and  pyogenes 
fojtidus,  proteus  vulgaris,  and  others  have  been  encoun- 
tered. In  most  cases  probably  a  mixed  infection  (several 
varieties  of  micro-organisms)  takes  place.  The  bacterium 
coli  commune,  however,  is  most  frequently  found,  as  it  has 
a  greater  resisting-power  and  in  the  course  of  its  growth 
usually  causes  disappearance  of  the  other  micro-organ- 
isms. 

Sex  and  age  seem  to  play  an  important  part  in  regard  to 
the  distribution  of  the  disease.  The  male  sex  is  much  more 
frequently  affected  than  the  female.     Thus, 

Sonnenburg  reports  130  cases —  77  males,  53  females. 

Rotter  "  68     "     —  44      "  24 

Nothnagel        "  130    "     —105      "  25 

Bamberger*     "  73     "     _  54      "  19        " 

'  Tavel  und  Lanz  :  "  Ueber  die  Aetiologie  der  Peritonitis.  "  Mitthei- 
lungen  aus  Kliniken  und  Instituten  der  Schweiz,  Basel,  1893. 

*  Hodenpyl :  "  On  the  Etiology  of  Appendicitis.  "  New  York  Medi- 
cal Journal,  1893. 

3  E.  Wilson  :  Cited  after  Fowler. 
^Barbacci :  Lo  sperimentale,  1893,  fasc.  4. 

*  Bamberger :  "  Die  Entzi\ndungen  der  rechten  Fossd  iliaca. " 
Wiener  med.  Wocbensclir.,  1853. 


APPENDICITIS. 

Volz  '  reports  _  59  cases—  45  males,     14  females. 

Matterstock*      "     l!o30    "     —733      "       297 


20^ 


This  preponderance  of  the  male  sex  is  already  found  in 
early  life.  Thus  Matterstock  observed  72  cases  of  appen- 
dicitis in  early  life  (seven  months  to  fifteen  years),  and 
among  this  number  were  51  male  children  and  21  girls. 
The  greater  frequency  of  appendicitis  in  the  male  sex  is 
explained  by  Van  Cott  as  due  to  the  circumstance  that  the 
appendix  of  the  male  has  a  less  abundant  blood  supply 
than  that  of  the  female ;  for  in  the  latter  there  is  a  col- 
lateral circulation  derived  from  the  sexual  apparatus. 

With  regard  to  age  all  writers  agree  that  appendicitis  is 
most  frequently  encountered  between  the  tenth  and  thir- 
tieth years.  It  occurs  less  frequently  in  the  first  decade 
of  life  and  in  the  thirtieth  to  fortieth  years,  and  is  quite 
rare  in  advanced  age.  The  following  table  is  submitted 
with  a  view  of  showing  the  frequency  of  appendicitis  in 
the  different  decades  of  life  as  recorded  by  several  eminent 
writers : 


Ages. 

Fitz. 

Matterstock. 

Nothnagel. 

Total  number        

228 

22 
86 
65 
34 

8 
11 

1 
1 

474 

46 
143 

158 

72 

30 

18 

5 

2 

129 

1  to  10 

1 

10  to  20 

44 

20  to  30 

57 

30  to  40 

14 

40  to  50 

7 

50  to  60 

4 

60  to  70 

2 

70  to  80 

0 

The  frequency  of  appendicitis  in  relation  to  other  dis- 
eases can  be  studied  from  the  report  of  the  autopsies  made 

'  Ad.  Volz  :  "  Die  durch  Kothsteine  bedingte  Perforation  des  Wiirra- 
fortsatzes,  etc.,  "  Karlsruhe,  1846. 

-Matterstock:  "Perityphlitis."  Gerhardt's  Handbuch  der  Kinder- 
krank.,  Tiibiugen,  18S0. 


202  DISEASES  OP  THE  INTESTINES. 

in  the  pathological  institute  of  the  Wiener  Allgemeiue 
Krankenhaus  between  1870  and  1896.  According  to  Noth- 
nagel,  the  total  number  of  autopsies  was  44,940.  Among 
these  the  number  of  cases  dying  from  ai^pendicitis  amounted 
to  148.  The  percentage  of  appendicitis,  therefore,  was 
0.32.  With  regard  to  sex  there  were  107  males  (72.3  per 
cent)  and  41  females  (27.7  per  cent).  The  actual  fre- 
quency of  appendicitis  among  the  living,  however,  is  much 
greater  than  appears  from  these  numbers,  which  relate 
only  to  cases  which  have  resulted  fatally. 

Morbid  Anatomy. — The  pathological  anatomy  of  appen- 
dicitis has  been  thoroughly  studied  recently,  not  only  in 
autopsies  but  principally  in  operative  cases.  In  the  latter 
an  insight  is  permitted  into  the  changes  which  take  place 
early  in  the  disease.  Fowler  distinguishes  four  stages  of 
anatomical  lesions  according  to  the  spread  of  the  morbid 
process  involving  the  different  tissues  of  the  appendix.  In 
the  first  stage  (endo-ai)pendiciti8)  more  or  less  intense  in- 
flammation of  the  mucous  and  submucous  layers  takes 
place.  The  second  stage  (parietal  appendicitis)  consists 
in  an  inflammatory  j^rocess  involving  the  interstitial  or 
intermuscular  structure  of  the  body  of  the  appendix.  The 
third  stage  (peri-appendicitis)  means  an  inflammatory  i:>roc- 
ess  involving  all  the  layers  of  the  appendix,  the  peritoneum 
included.  The  fourth  stage  (para-appendicitis)  consists  in 
lesions  involving  the  appendix  and  the  neighboring  tissues. 
This  process  is  most  often  accompanied  with  sujjpurative 
inflammations  of  the  connective  tissue  adjacent  to  that  por- 
tion of  the  appendix  which  is  not  covered  with  perito- 
neum. 

According  to  Fowler,  the  above  described  stages  aie  not 
essentially  different  processes  but  further  developments  of 
one  and  the  same  lesion. 


APPENDICITIS.  203 

Riedel, '  Notlinagel,  and  others  distinguish  two  different 
tyjjes  of  appendicitis  which  are  of  great  clinical  importance. 
They  are  the  following : 

1.  Catarrhal  appendicitis  (endo-apjjendicitis) .  Here  in  the 
acute  form  the  mucosa  of  the  appendix  is  swollen  and  red- 
dened, the  submucosa  is  engorged  and  filled  with  round 
cells.  The  follicles  are  distinctly  swollen.  The  appendix 
appears  swollen  and  more  rigid,  and  its  lumen  is  filled  with 
thick  yellowish  contents,  mostly  mucus;  sometimes  the 
latter  may  be  mixed  with  fecal  matter.  Occasionally  there 
are  fecal  concretions.  Often  ecchymoses  of  the  mucosa 
occur,  leading  sometimes  to  superficial  defects  (erosions) . 
All  these  lesions  may  entirely  disappear  after  the  acute  at- 
tack is  over,  aud  thus  a  perfect  cure  may  be  established. 
This,  however,  is  possible  only  if  there  is  no  occlusion  of 
the  lumen  of  the  appendix  and  the  inflammatory  i^roducts 
can  be  emptied  into  the  caecum. 

In  the  large  majority  of  cases  of  catarrhal  appendicitis 
the  cure  is  not  a  i)erfect  one  aud  chronic  appendicitis  is 
the  result.  In  this  stage  the  mucosa  of  the  appendix 
presents  a  slate-gray  ai)pearance.  It  is  filled  with  accumu- 
lations of  round  cells;  at  the  same  time  proliferation  of 
connective  tissue  and  occasionally  blood  pigment  are  found. 
The  submucosa  and  muscularis  may  show  no  changes 
whatever,  although  as  a  rule  they  are  hypertrophied.  The 
latter  condition  is  probably  due  to  stricture  of  the  lumen 
of  the  apjiendix  aud  consecutive  muscular  (compensatory) 
hypertrophy.  The  chronic  form  of  appendicitis,  owing  to 
suppurative  processes  of  the  mucous  membrane,  occasion- 
ally leads  to  a  total  destruction  of  the  mucosa,  and  an  ob- 
literation of  the  lumen  of  the  appendix.     This  condition  is 

'  Riedel :  "Ueber  die  Friihoperation  bei  Appendicitis  punilenta  seu 
gangraenosa."    Berl.  kliu.  Wocheusclir. .  1899,  Nos.  33  and  34. 


204  DISEASES  OF  THE  INTESTINES. 

very  similar  to  obliteration  of  the  lumen  due  to  the  involu- 
tion processes  which  have  been  mentioned  above.  The 
ai)pendix  then  forms  a  solid  membranous  band  of  uniform 
thickness  or  with  a  few  small  protrusions.  As  a  rule  it  is 
found  embedded  in  peritouitic  adhesions. 

Sometimes  i)rimary  slight  lesions  of  the  appendix  lead 
to  complications,  especially  if  a  stricture  is  present.  Thus 
an  accumulation  of  secretion  within  the  occluded  appen- 
dicular cavity  may  take  i^lace  and  give  rise  to  the  forma- 
tion of  a  cyst.  Such  cysts  occur,  varying  in  size  from  a 
cherry  to  a  fist.  Guttmann '  observed  a  cyst  of  the  appen- 
dix fourteen  centimetres  (five  and  a  h«alf  inches)  long  and 
twenty-one  centimetres  (eight  and  a  quarter  inches)  wide. 
The  contents  of  such  a  cyst  are  either  of  a  watery  mucous 
character  or  gelatinous. 

If  ulceration  takes  place  in  the  occluded  appendicular 
cavit}',  it  may  give  rise  to  the  formation  of  a  small  abscess 
(l)y-appendix  or  empyema  processus  vermiformis).  In 
these  cases  the  purulent  process  may  penetrate  the  wall 
of  the  appendix  and  lead  to  perforation.  A  timely  opera- 
tion in  many  instances  prevents  such  an  outcome. 

2.  The  severe  form  of  appenduntis  (appendicitis  vlcerosa 
et  (jtunjrd'iiosa,  appendicitis  perforativa) .  In  this  grou]) 
the  bacterial  infection  is  of  a  much  more  virulent  nature 
than  in  the  catarrhal  form.  The  inflammation  originating 
in  the  mucosa  of  the  appendix  at  once  involves  all  its  lay- 
ers, including  the  serosa.  Necrobiotic  processes  and  for- 
mation of  pus  take  place  quite  early.  The  peritoneum  is 
also  very  soon  involved,  either  in  the  immediate  neighbor- 
hood of  the  appendix  or  in  its  entirety.  Ulcerations  and 
gangrenous  processes  may  lead  to  the  destruction  of  a 

'  P.  Guttmann  :  Verliandluiigen  des  Vereiiis  fiir  innere  Medicin  zu 
Berlin,  1883-84,  p.  301. 


APPENDICITIS.  205 

part  of  the  appendix,  thus  causing  perforation,  or  to  a  total 
necrosis  of  the  entire  appendix.  As  a  result  of  this  proc- 
ess the  latter  may  be  cast  off  from  the  caecum  and  be  found 
free  in  the  peritoneal  cavity  or  embedded  in  pus. 

The  way  in  which  the  peritoneum  is  involved  is  quite 
variable.  There  may  be  an  adhesive  tyi)e  of  peritonitis 
leading  to  a  matted  and  agglutinated  condition  of  the  ap- 
pendix, or  a  circumscribed  or  diffuse  peritonitis  without 
adhesions.  The  contents  of  the  appendix  may.  be  emptied 
into  the  abdominal  cavity  or  hemmed  in  by  adhesions. 
The  size,  location,  and  direction  of  the  abscess  differ 
greatly.  The  location  and  length  of  the  appendix  and  the 
portion  perforated  play  an  important  part  in  this  respect. 
In  the  great  majority  of  cases  the  abscess  is  at  first  intra- 
peritoneal, but  very  soon  extends  toward  the  surface  or 
above  or  below  Poupart's  ligament.  Again  it  may  pene- 
trate into  the  bladder,  vagina,  small  intestine,  or  rectum. 
In  some  instances  it  reaches  the  diaphragm  and  from 
there  perforates  into  the  pleural  cavity. 

In  some  very  grave  cases  there  is  no  abscess  but  a  dif- 
fuse peritonitis.  Here  we  often  meet  with  a  paretic  con- 
dition of  the  intestine,  the  latter  being  filled  with  gas ;  the 
serous  layer  is  shiny  and  red,  while  there  is  an  absence  of 
any  exudation.  In  other  cases  a  small  quantity  of  a  purely 
serous  or  bloody  serous  exudation  is  found.  The  condi- 
tion just  described  may  be  discovered  either  in  oi>erations 
undertaken  very  early  or  at  autopsies  in  cases  which  ter- 
minate fatally  at  the  beginning  of  the  disease.  In  still  an- 
other group  of  cases  which  is  a  comparatively  very  small 
one,  the  general  peritonitis  may  assume  a  more  protracted 
and  chronic  form.  In  these  cases  mattings  and  adhesions 
are  formed  over  more  or  less  large  areas  of  the  abdominal 
cavity,  and  in  these  accumulations  of  pus  may  be  found. 


206  DISEASES  OP  THE  INTESTINES. 

Apiiendicitis  due  to  tuberculosis  is  of  comparatively  rare 
occurrence  and  shows  a  great  tendency  to  the  formation  of 
fistulse.  Recently  actinomycosis  has  been  found  to  be  the 
cause  of  some  cases  of  appendicitis  with  the  formation  of 
abscesses.  In  these  cases  the  actinomycosis  fungi  can 
easily  be  demonstrated. 

Symptomatology. — In  describing  the  symptomatology  of 
appendicitis  it  will  again  be  best  to  differentiate  the  two 
forms  already  mentioned  above,  namely,  the  catarrhal  and 
the  severe  form. 

1.  Catarrhal  or  eu do-appendicitis.  An  attack  of  aj^pendi- 
citis  is  usually  characterized  by  a  sudden  appearance  of 
pain  in  the  abdominal  cavity,  which  at  first  may  be  dif- 
fused or  in  the  region  of  the  navel,  but  very  soon  is  local- 
ized in  the  right  iliac  region.  A  moderate  rise  of  temper- 
ature is  very  frequently  present.  Slight  gastric  symptoms, 
nausea,  and  sometimes  vomiting  often  occur,  but  are,  as  a 
rule,  only  transient.  The  pains  usually  increase  in  inten- 
sity, and  the  patient  assumes  a  fixed  position  with  the  legs 
flexed.  Any  change  in  the  position  or  any  movement  of 
the  thighs  increases  the  pain.  Examination  by  palpation 
shows  extreme  tenderness  on  i^ressure  of  the  right  iliac  re- 
gion, more  especially  at  McBumey's  point,  while  the  rest 
of  the  abdomen  can  be  examined  by  pressure  without  giv- 
ing rise  to  the  slightest  pain.  "While  the  pains  are  gener- 
ally continuous,  they  may  show  periods  of  exacerbation. 
The  latter,  according  to  Nothnagel,  are  most  probably  due 
to  a  spastic  contraction  of  the  muscles  of  the  ai)pendix. 

The  term  "  appendicular  colic  "  has  been  given  by  Tala- 
mon  to  the  same  condition.  Talamon,  however,  assumed 
that  the  colic  is  always  due  to  an  attempt  of  the  appendix 
to  rid  itself  of  a  fecal  concretion.  Inasmuch  as  operations 
for  appendicitis  have  often  been  i^erformed  during  the  at- 


APPENDICITIS.  207 

tack  of  colic  and  no  fecal  concretions  whatever  found  in 
the  appendix,  and  inasmuch  as  coproliths  have  been  found 
in  cases  in  which  no  colic  whatever  existed,  this  theory 
cannot  be  maintained. 

In  some  cases  there  is  an  area  of  resistance  in  the  right 
iliac  region.  If  the  latter  be  due  to  an  accumulation  of 
fecal  matter  in  the  csecum,  the  tumor  can  be  slightly  moved 
and  its  shape  changed  by  pressure.  In  a  few  of  the  cases 
of  catarrhal  appendicitis  the  resistance  is  due  to  an  inflam- 
matory swollen  (serous)  condition  of  the  appendix  and  of 
the  neighboring  organs.  In  this  instance  the  tumor  is  not 
circumscribed  but  rather  diffuse,  immovable,  and  its  shape 
unaffected  by  pressure. 

In  comparatively  few  cases  can  the  appendix  be  directly 
palpated.  It  then  appears  as  an  elongated  round  body  of 
the  size  of  the  little  finger,  and  is  very  painful  on  pressure. 
The  examination  of  the  appendix  itself,  whenever  this  is 
possible,  is  certainly  of  the  utmost  importance  for  diagno- 
sis. Edebohls  '  deserves  much  credit  for  having  cultivated 
and  perfected  the  method  of  examining  the  appendix  by 
palpation.  According  to  Edebohls,  this  examination  is  best 
done  as  follows :  The  patient  lies  upon  his  back  with  the 
legs  comfortably  flexed.  The  physician  standing  at  the 
patient's  right  begins  to  search  for  the  appendix  by  apply- 
ing two,  three,  or  four  fingers  of  his  right  hand,  palmar 
surface  downward,  almost  flatly  upon  the  abdomen  at  or 
near  the  umbilicus ;  while  now  he  draws  the  examining  fin- 
gers over  the  abdomen  in  a  straight  line  from  the  umbili- 
cus to  the  anterior  superior  spine  of  the  right  ilium,  he 
notes  successively  the  character  of  the  various  structures 
as  they  come  beneath  and  escape  from  the  fingers  passing 
over  them.  In  doing  this  the  pressure  exerted  must  be 
'  Edebohls  :  American  Journal  of  tlie  Medical  Sciences,  May,  1894. 


208  DISEASES  OF  THE  INTESTINES. 

strong  enough  to  recognize  distinctly  along  the  whole 
route  traversed  by  the  examining  fingers  the  resistant  sur- 
face of  the  posterior  abdominal  wall  and  of  the  pelvic  brim. 
Only  in  this  way  can  we  positively  feel  the  normal  or 
slightly  enlarged  appendix.  Pressure  short  of  this  must 
necessarily'  fail. 

R.  T.  Morris  '  suggests  for  Edebohls'  method  of  palpating 
the  use  of  three  right-hand  fingers  to  feel  with  and  three 
left-hand  fingers  placed  upon  these  to  press  with.  The 
fingers  that  are  to  do  the  feeling  are  pressed  by  means  of 
the  three  others  down  to  the  border  of  the  right  rectus  ab- 
dominalis  muscle  at  the  level  of  the  navel  and  slowly  drawn 
toward  the  examiner.  I  have  found  both  these  methods 
very  useful  in  detecting  the  position  and  size  of  the  ap- 
pendix. 

The  temperature  is  usually  but  slightly  raised,  some- 
times even  normal.  The  pulse  likewise  is  either  normal 
or  but  moderately  accelerated. 

Constipation  is  often  present,  but  seems  to  be  rather  the 
result  of  the  inflammatory  condition  of  the  appendix  than 
its  cause,  as  was  formerly  believed.  In  a  comparatively 
small  number  of  cases  diarrhoea  is  present  during  the  at- 
tack of  appendicitis. 

Course.  — An  acute  attack  of  catarrhal  appendicitis  may 
last  from  two  to  three  days  to  two  to  three  weeks.  After 
this  variable  period  of  sickness  the  symptoms  either  en- 
tirely disappear  or  ])ersist  in  a  slight  degree.  With  regard 
to  the  further  development  the  following  classes  must  be 
distinguished:  1.  There  may  be  complete  recovery  without 
any  further  trouble.  2.  The  patient  may  entirely  recover 
from  the  present  attack,  but  have  a  return  of  the  disease 
after  a  variable  period  of  time  (from  a  few  weeks,  a  few 

'  R.  T.  Morris :  "Lectures  on  Append icitis,"  New  York,  1899,  p.  45. 


APPENDICITIS.  209 

montlis  to  a  year  or  two) — "  recurrent  appendicitis. "  3. 
The  symptoms  may  not  completely  disappear  but  may 
persist  for  many  weeks  and  the  patient  may  remain  in  a 
lingering  condition — "subacute  or  chronic  appendicitis." 

The  first  class  of  perfect  recoveries  is  comparatively  small. 
In  this  group  there  is  either  an  obliteration  of  the  appen- 
dix or  the  catarrhal  process  may  have  subsided  completely 
without  having  left  behind  any  lesions.  The  second  cla.s8 
of  recurrent  apjiendicitis  comprises  the  majority  of  the 
cases.  In  these  a  chronic  catarrhal  condition  of  the  mu- 
cosa of  the  appendix  may  persist  without  manifesting 
symi)toms  until  a  new  invasion  of  micro-organisms  gives 
rise  to  an  acute  exacerbation  of  the  process,  or  strictures 
of  the  lumen  of  the  appendix  maj-  have  formed  as  a  conse- 
quence of  the  acute  attack  and  thus  become  the  cause  of 
renewed  disturbances  later  on.  In  the  third  category  the 
catarrhal  appendicitis  has  led  to  severe  anatomical  lesions. 
There  may  be  a  considerable  thickening  of  the  appendix 
wall  including  the  serosa.  The  api:>endicular  lumen  may 
show  ulcerations,  strictures,  or  bends.  There  may  also 
be  an  accumulation  of  pus  (pj-appendix). 

2.  The  severe  form  of  appendicitis  {appendicitis  suppura- 
tiva or  perforans).  The  disease  usually  begins  quite  sud- 
denly in  the  midst  of  perfect  health ;  rarely  it  is  preceded 
by  slight  digestive  disturbances.  The  patient  is  seized  with 
violent  pains  in  the  abdomen.  These  are  felt  at  first  either 
over  the  entire  abdomen,  in  the  epigastric  region,  or  on 
the  left  side  of  the  abdomen,  but  very  soon  they  settle  in 
the  right  iliac  region.  The  pains  are  of  an  intense  charac- 
ter, and  occasionally  are  accompanied  by  paroxysms  dur- 
ing which  they  are  almost  unbearable.  Any  motion  in- 
creases the  pain.     The  i)atient  lies  i)erfectly  motionless 

and  breathes  supei-ficiallv.     The  appearance  is  that  of  a 
14 


210  DISEASES  OP  THE  INTESTINES. 

very  sick  person,  the  countenance  manifests  great  suflfer- 
ing  and  anxiety.  The  temperature  is  usually  considerably 
increased  and  continues  so  during  the  first  days  of  the  dis- 
ease. The  pulse  is  accelerated.  Occasionally  it  is  of 
small  calibre,  easily  compressible,  and  at  times  irregular. 
The  latter  phenomena  are  found  principally  in  critical 
conditions.  A  very  frequent  pulse  and  a  comparatively 
low  degree  of  fever  are  also  considered  bad  omens.  There 
is  always  complete  anorexia  and  great  thirst,  the  tongue 
is  dry  and  thickly  coated,  the  bowels,  as  a  rule,  are  con- 
stipated. In  rare  instances  there  is  diarrhoea.  Accord- 
ing to  Nothnagel,  vomiting  is  present  in  almost  three- 
quarters  of  the  cases.  It  usuallj'  appears  right  at  the 
commencement  of  the  disease  and  lasts  only  a  short  time. 
In  exceptional  instances  it  iiersists  for  several  days.  The 
vomited  matter  consists  of  gastric  contents,  mucus,  and 
bile.  In  very  grave  cases  it  exceptionally  assumes  a  fecu- 
lent character.  The  vomiting  is  occasionally  accompanied 
by  hiccoughs.  Beth  these  phenomena  are  very  annoying 
and  at  the  same  time  increase  the  pain  through  the  mo- 
tions evoked  by  them. 

In  many  of  the  cases,  soon  after  the  commencement  of 
the  disease  a  tumor  begins  to  form  in  the  right  iliac  re- 
gion. At  first  a  rigidity  of  the  muscles  in  this  region  is 
noted;  later  on  a  distinct  resistance  over  an  area  of  egg 
size  may  be  found.  The  tumor  is  either  circumscribed 
and  sharply  defined,  or  it  is  diffuse  and  connected  with 
the  neighboring  tissues.  The  skin  over  the  tumor  is  as 
a  rule  easily  movable,  while  the  latter  is  immovable.  The 
tumor  generally  consists  of  a  purulent  exudation  in  and 
around  the  appendix  and  congested  portions  of  the  intes- 
tines, occasionally  of  the  omentum,  and  of  a  purulent  infil- 
tration of  the  abdominal  wall  itself.     In  some  instances 


APPENDICITIS.  211 

the  size  of  the  tumor  is  considerably  increased  by  an  ac- 
cumulation of  fecal  matter  in  the  caecum.  The  tumor  may 
be  discovered  by  palpation  and  sometimes  by  percussion. 
Fluctuation  is  present  only  in  very  extensive  abscesses. 
Its  absence  does  not  signify  the  absence  of  pus.  The  re- 
sistance as  a  rule  increases  either  very  slowly  or  quite 
rapidly.  In  rare  instances,  namely  in  those  in  which  the 
abscess  is  surrounded  by  a  firm  capsule,  it  may  remain 
unchanged  for  a  long  time.  The  abscess  occasionally  in- 
volves the  muscles  and  even  the  skin  lying  above  it.  The 
latter  becomes  infiltrated  and  oedematous,  and  in  rare  in- 
stances the  abscess  may  spontaneously  open  through  the 
skin.  Occasionally  the  resistance  disappears  entirely  when 
the  purulent  exudation  has  descended  into  the  deeper  parts. 
In  such  an  event,  by  an  examination  through  the  rectum, 
and  in  females  through  the  vagina,  the  exudation  may  be 
discovered  filling  Douglas'  space. 

In  cases  in  which  there  is  an  extensive  inflammation  of 
the  peritoneum  accompanied  by  a  considerable  quantity  of 
pus,  severe  pains  in  urination  appear  quite  early,  after  two 
or  three  days  (Fleischer).  On  this  account  the  patients  are 
often  rather  afraid  to  urinate.  In  the  same  cases  there 
may  also  be  parsesthesia  and  anaesthesia  in  the  limbs,  or 
obstinate  erections  of  the  penis,  or  a  drawing  up  of  the 
right  testicle.  These  symptoms  all  show  that  the  accumu- 
lation of  pus  presses  upon  the  nerves  of  the  sacral  plexus. 

The  furtlier  course  of  the  disease  will  largely  depend 
upon  the  way  in  which  the  newly  formed  i^us  around  the 
appendix  acts.  Often  it  leads  to  a  perforation  of  the  ap- 
pendix. Sometimes  the  abscess  forms  adhesions  and  is 
encai)suled.  Sometimes,  again,  the  abscess  penetrates  into 
the  peritoneal  cavity  and  gives  rise  to  diffuse  septic  or 
fibrino-purulent  peritonitis. 


212  DISEASES  OP  THE  INTESTINES. 

Perforaticm  of  the  appendix  which  occurs  quite  fre- 
quently in  this  class  of  cases  is  accompanied,  according 
to  Sonnenburg,  by  the  following  symptoms:  The  disease 
begins  with  febrile  and  marked  symptoms ;  violent  jjains 
in  the  abdomen  appearing  either  suddenly  or  after  a  short 
l)eriod  of  slight  uneasiness  and  concentrating  very  quickly 
in  the  right  side ;  vomiting  accompanied  by  diarrhoea  and 
in  other  cases  by  constipation;  small  and  frequent  pulse; 
fever  commencing  with  chills  and  quickly  rising;  pro- 
nounced tympanites;  general  appearance  extremely  bad; 
slight  cyanosis  and  perspiration ;  a  distinct  area  of  resist- 
ance over  or  around  the  affected  spot.  While  all  theqe 
symptoms  are  certainly  found  in  cases  of  perforation  of 
the  api^endix,  they  can  by  no  means  be  absolutely  relied 
upon ;  for  they  may  exist  in  the  same  manner  without  a 
I)erforation  taking  place,  and,  on  the  other  hand,  the  lat- 
ter event  may  occur  without  any  of  the  above-mentioned 
symptoms  being  present.  For  these  reasons  Boas  '  is  re- 
luctant to  make  the  diagnosis  of  perforative  appendicitis, 
and  contents  himself  with  determining  the  presence  of 
purulent  appendicitis. 

Perforation  peritonitis  most  often  appears  between  the 
second  and  fourth  days  of  the  disease  (Fitz).  The  danger 
of  a  penetration  of  pus  into  the  free  peritoneal  cavity  less- 
ens with  the  length  of  time  the  disease  has  lasted,  on  ac- 
count of  the  formation  of  adhesions.  On  the  other  hand, 
numerous  other  perilous  events  may  take  place.  In  some 
cases  a  few  days  after  the  commencement  of  the  disease 
there  is  a  subsidence  of  the  most  important  symptoms 
(pains,  fever,  etc.),  while  in  others  they  persist  with  undi- 
minished severity.     Even  in  the  first  class,  however,  the 

'  J.  Boas :  "  Dlagnostik  und  Therapie  der  Darmkrankheiten, "  Leip- 
zig, 1899. 


APPENDICITIS.  213 

amelioration  rarely  persists,  for  pretty  soon  afterward  the 
pains  reappear  and  the  fever  recurs,  and  in  connection 
with  these  symptoms  the  inflammation  increases  and  the 
pus  augments.  Periods  of  improvement  and  exacerbation 
of  tlie  condition  may  alternate  for  (^uite  a  while  until  at 
last  either  recovery  or  a  fatal  issue  ensues. 

A  spontaneous  cure  or  recovery  without  surgical  inter- 
vention may  occur  in  one  of  the  following  ways : 

1 .  The  abscess  may  become  encapsulated,  the  pus  losing 
its  virulence  and  becoming  absorbed.  In  such  an  event  the 
tumor  disappears  and  the  patient  is  either  definitely  or  ap- 
jmrently  cured ;  for  dangers  to  life  remain  after  such  a  cure 
in  consequence  of  the  remnants  of  the  abscess  and  of  the 
adhesions  formed  among  the  intestines.  "  The  occurrence 
of  a  sudden  bursting  of  the  abscess,"  using  Ewald's  words, 
"  hangs  like  the  sword  of  Damocles  over  the  head  of  the 
patient  as  long  as  there  is  still  i)us  present. "  In  seemingly 
perfect  health  a  fatal  peritonitis  may  thus  occur  in  patients 
w^ho  had  previously  suffered  from  an  attack  of  appendicitis. 

2.  A  cure  may  be  established  by  the  opening  of  the 
abscess  into  adjacent  hollow  viscera.  Thus  the  abscess 
may  open  into  the  caecum,  colon,  small  intestine,  bladder, 
vagina,  or  pelvis  of  the  kidney.  This  favorable  issue  is, 
however,  rare. 

3.  The  abscess  may  find  its  way  externally  by  ruptur- 
ing spontaneously  through  the  skin.  Sometimes,  however, 
the  pus  burrows  into  other  organs ;  thus  it  may  reach  the 
diaphragm  (subphrenic  abscess),  and  sometimes  even  force 
its  way  through  into  the  pleural  cavity  and  perhaps  the 
lungs.  But  even  from  these  places  the  pus  may  be  evacu- 
ated spontaneously,  principally  through  rupture  into  a 
bronchus  and  its  expulsion  during  a  coughing  spell. 

In  a  large  number  of  cases  peritonitis  and  septicemia 


214  DISEASES  OF  THE  INTESTINES. 

terminate  the  life  of  the  patient ;  in  others  after  recovery 
there  are  frequently  grave  recurrences  of  the  disease. 

Diagnosis. — Catarrhal  appendicitis  can  be  diagnosed  if 
there  is  a  sudden  onset  of  pain  in  the  right  abdominal  cav- 
ity, principally  in  the  region  of  the  appendix,  combined 
usually  with  a  slight  rise  of  temperature  and  some  light 
gastric  symptoms  (nausea,  anorexia,  vomiting).  The 
grave  form  of  the  disease  or  purulent  appendicitis  shows 
the  same  manifestations,  only  of  a  much  severer  type. 
Besides  there  are  always  present  signs  of  serious  illness. 
The  patient  is  very  pale  and  manifests  an  anxious  ap- 
pearance. Chills  are  frequently  present  and  the  tempera- 
ture shows  a  certain  irregularity  in  its  course.  There  may 
be  a  marked  rise  in  temperature  after  it  has  been  quite 
low  or  almost  normal  for  a  time. 

The  presence  of  a  tumor  in  the  right  iliac  region  is  of 
great  importance  in  the  diagnosis  of  appendicitis,  although 
this  symptom  is  frequentlj'  absent.  In  order  to  recognize 
the  nature  of  the  tumor  with  regard  to  its  contents,  espe- 
cially whether  pus  is  present  or  not,  Sahli  first  suggested 
the  use  of  an  exploratory  puncture.  If  pus  can  be  aspi- 
rated through  the  needle,  then  an  abscess  is  positively 
present.  Although  many  physicians  make  use  of  this 
method  even  nowadays,  as  for  instance  Ley  den,'  Noth- 
nagel,  Penzoldt,"  Fleischer,  Boas,  and  others,  most  of  the 
surgeons  are  decidedly  opposed  to  this  diagnostic  measure 
(Fowler,  Treves,"  Sonnenburg,  and  others).  In  this  coun- 
try the  consensus  of  opinion  is  against  the  use  of  exjjlora- 
tory  puncture,  for  its  employment  adds  a  new  element  of 

•E.  von  Leyden  :  Berl.  klin.  Wochenschr. ,  1889.  No.  31. 

'Penzoldt:  "Behandlung  der  Erkrankungen  des  Darms. "  Pen- 
zoldt-Stintzing's  "Handbucli  der  speciellen  Therapie  innerer  Krank- 
heiten, "  Jena,  1896. 

'  Treves :  "  On  Peritonitis."    British  Medical  Journal,  1894. 


APPENDICITIS.  215 

danger  to  the  case,  while  its  results,  especially  if  negative, 
are  unreliable. 

While  appendicitis  can  usually  be  diagnosed  without 
difficulty,  in  some  instances  its  recognition  is  quite  diffi- 
cult. In  cases  in  which  the  appendix  is  abnormally  situ- 
ated, as  for  instance  in  the  left  iliac  region  or  in  the  upper 
l)art  of  the  right  abdominal  cavity,  the  diagnosis  of  appen- 
dicitis" will  hardly  be  possible. 

Differential  Diagnosis. — The  following  conditions  may  at 
times  be  confounded  with  api^endicitis,  namely,  biliary, 
renal,  and  intestinal  colic.  The  following  points  will  serve 
as  a  guide  in  making  a  correct  diagnosis.  In  biliary  colic 
the  pains  are  referred  hj  the  patient  to  the  right  abdominal 
cavity,  radiating  to  the  back  and  up  to  the  shoulders.  Pal- 
pation shows  a  painful  area  situated  immediately  below  the 
right  margin  of  the  ribs ;  occasionally  jaundice  is  present. 
In  kidney  colic  (right  side)  the  pain  is  felt  by  the  patient 
in  the  right  lumbar  region,  radiating  toward  the  bladder. 
There  is  generally  a  frequent  desire  for  micturition  and 
slight  burning  in  the  urethra.  The  urine  may  show  the 
presence  of  mucus,  sometimes  of  blood  and  pus  cells.  In 
intestinal  colic  the  i)ain  may  be  referred  to  the  right  iliac 
region,  but,  as  a  rule,  it  is  relieved  very  soon  after  the 
passage  of  flatus.  In  contradistinction  to  these  three  con- 
ditions the  pain  in  appendicitis  is  referred  to  the  right 
iliac  region,  where  it  remains  localized,  does  not  disappear 
upon  passage  of  flatus,  does  not  radiate  to  the  shoulder 
and  but  very  rarely  to  the  bladder,  while  there  is  also  great 
tenderness  and  pain  upon  pressure  at  McBurney's  point. 
No  jaundice  is  present  and  the  urine  is  normal. 

In  women  the  differential  diagnosis  between  appendici- 
tis and  a  right-sided  salj^iugitis  is  not  always  easily  made. 
A  thorough  examination  through  the  vagina,  however,  will 


216  DISEASES  OP  THE  INTESTINES. 

in  most  instancea  enable  us  to  decide  as  to  the  true  condi- 
tion. If  the  appendix  is  situated  in  the  small  pelvis  and 
has  given  rise  to  the  formation  of  an  abscess  in  this  local- 
ity the  decision  of  the  question  whether  the  abscess  is  due 
to  appendicitis  or  to  oophoritis  is  extremely  difficult  and 
sometimes  even  impossible.  Typhoid  fever  in  exceptional 
cases  may  simulate  an  appendicitis ;  the  presence  or  absence 
of  Widal's  reaction  will  serve  to  differentiate  the  former. 

Prognosis. — Catarrhal  ai)[)endicitis  affords  in  most  in- 
stances a  favorable  prognosis  as  regards  to  life.  With  ref- 
erence to  complete  recovery,  however,  the  outlook  is  by  no 
means  bright,  for  the  liability  to  recurrence  of  the  disease 
is  very  great.  Inasmuch  as  an  apparently  mild  form  of 
appendicitis  may  all  of  a  sudden  change  its  character  and 
assume  alarming  features,  the  prognosis  should  always  be 
made  with  a  certain  resers'e,  even  in  this  class. 

The  purulent  form  of  appendicitis  must  be  regarded 
as  a  very  serious  disease  and  gives  quite  an  unfavorable 
prognosis  unless  timely  surgical  intervention  is  adopted. 
The  intensity  of  the  symptoms  in  purulent  ajjpendicitis  is 
by  no  means  a  correct  measure  of  the  gravity  of  the  dis- 
ease. Experience  shows  that  cases  with  violent  symp- 
toms, very  high  fever,  and  intense  j^ains,  etc. ,  occasionally 
recover  within  a  few  days,  the  pus  rupturing  i\ito  the  intes- 
tine, while  apparently  mild  cases  after  a  few  days  of  sick- 
ness suddenly  develop  symptoms  of  a  general  septic  peri- 
tonitis with  a  fatal  issue.  Diffuse  peritonitis  is  liable  to 
occur  between  the  second  and  fourth  days  of  sickness,  but 
even  later  the  patient  is  subjected  to  numerous  risks. 
Grave  complications  may  suddenly  develop  even  in  a  pa- 
tient who  is  ai)i)arently  progressing  nicely  and  already 
convalescent-.  Thus  purulent  appendicitis  may  give  rise 
to  pyopneumothorax,  empyema,  or  purulent  pericarditis, 


APPENDICITIS.  217 

and  these  complications  may  result  in  a  fatal  issue.  The 
prognosis  of  perforating  appendicitis  is  decidedly  less  fa- 
vorable than  that  of  a  simple  empyema  of  the  appendix, 
as  in  the  former  septicaemia  is  liable  to  occur. 

After  having  described  the  numerous  dangers  present  in 
the  severe  form  of  appendicitis  it  is  consoling  to  say  that 
spontaneous  recoveries  are,  notwithstanding  this,  in  the 
majority.  With  regard  to  the  fre(iuency  of  spontaneous 
recoveries  Nothnagel  gives  the  following  statistics :  Among 
130  hospital  patients  he  observed  85  complete  recoveries, 
4  deaths  without  operation,  30  partial  recoveries,  and  11 
cures  after  operation.  The  large  number  of  cases  reported 
by  Sahli  is  also  very  important  in  this  connection.  This 
author  reports  the  results  in  7,213  cases  of  appendicitis; 
473  cases  were  operated  upon,  while  6,740  received  only 
medical  treatment.  Among  the  latter  6,194  recovered  (91.2 
per  cent)  while  591  (8.8  per  cent)  died.  Sahli  further 
states  that  of  the  4,593  cases  which  had  not  been  operated 
upon  and  in  which  inquiries  had  been  made  with  regard 
to  recurrence  of  appendicitis,  3,635  were  cured  without 
any  recurrence. 

Nothnagel  says  that  circumscribed  appendicitis  is  cura- 
ble in  the  large  majority  of  cases,  and  that  about  eighty 
per  cent  recover  under  simple  medical  treatment.  Among 
the  rest  there  are  still  some  that  can  be  cured  by  means 
of  operative  procedures.  Careful  watching  of  the  pa- 
tient and  timely  surgical  intervention  in  proper  cases 
may  reduce  the  number  of  deaths  from  appendicitis  to 
perhaps  five  per  cent  or  three  per  cent.  It  is,  however, 
impossible  entirely  to  avoid  fatal  issues,  even  with  the 
greatest  and  strictest  watchfulness.  Aside  from  accidental 
complications  and  from  rare  cases  in  which  a  correct  diag- 
nosis is  hardly  to  be  made,  there  remain  instances  in  which 


218  DISEASES  OF  THE  INTESTINES. 

the  peritoneum  is  diffusely  affected  quite  early  without 
presenting  any  symptoms.  These  are  the  cases  which 
make  the  prognosis  unfavorable  and  they  form  the  great- 
est contingent  of  deaths  among  patients  with  appendicitis. 
The  acute  septic  form  with  perforation  of  the  appendix  is 
the  most  dangerous,  while  the  progressive  suppurative  form 
is  comparatively  favorable. 

Treatment. — With  reference  to  prophylaxis  the  swallow- 
ing of  ffuit  pits,  of  very  small  bones,  and  coarse,  indi- 
gestible matter  in  the  food  was  formerly  strictly  forbidden. 
Nowadays,  however,  we  know  that  the  above-named  sub- 
stances play  no  part  whatever  in  the  etiology  of  appendi- 
citis. Regulation  of  the  bowels  or,  more  practically  speak- 
ing, correcting  constipation  has  been  believed  to  be  of 
importance  in  preventing  appendicitis.  This  maxim  can 
likewise  not  be  maintained  on  the  ground  of  recent  re- 
searches. Regularity  of  the  bowels  is  in  itself  of  impor- 
tance, and  hence  it  will  be  advisable  to  pay  attention  to 
this  factor.  The  only  means  we  possess  of  preventing  an 
attack  of  appendicitis  is  the  removal  of  the  appendix. 
While  this  suggestion  is  not  generally  practicable,  for  it 
requires  an  operation  which  is  not  entirely  without  risk, 
it  may,  however,  be  carried  out  in  cases  requiring  a  lap- 
arotomy for  other  diseases,  provided  that  this  additional 
operation  does  not  demand  too  much  time. 

The  medical  treatment  of  appendicitis  consists  in  abso- 
lute rest  of  the  entire  body,  especially  of  the  intestinal 
tract,  and  in  appropriate  diet.  The  ijatient  must  be  kept 
strictly  abed  from  the  commencement  of  the  disease  until 
it  is  entirely  over.  He  should  not  be  permitted  to  leave 
the  bed  for  a  moment.  He  must  lie  perfectly  quiet ;  even 
turning  from  one  side  to  the  other  should  be  avoided,  or  if 
done,  performed  with  the  greatest  care.     In  taking  nour- 


APPENDICITIS.  219 

ishment  the  head  may  be  slightly  raised ;  the  urine  should 
be  voided  in  a  glass,  and  an  evacuation  of  the  bowels 
should  take  place  in  a  bed-pan.  During  this  act  the  pa- 
tient must  be  forbidden  to  strain  or  exert  himself  in  any 
way.  The  utensils  needed  must  be  handled  by  the  nurse, 
who  must  also  attend  to  the  cleansing  of  the  patient. 

The  principle  of  rest  miust  also  be  applied  with  reference 
to  diet.  During  the  first  few  days  of  illness  there  should 
be  either  total  abstinence  from  food  (only  small  quantities 
of  water  being  given  now  and  then),  or  liquid  food  in  small 
portions.  Thus  strained  barley  water,  or  this  with  the 
addition  of  a  little  milk,  oatmeal  water  and  rice  water 
given  in  the  same  way,  chicken  soup,  very  weak  tea.  In 
the  very  severe  forms  of  appendicitis,  especially  when  per- 
foration has  taken  place,  or  when  sj^mptoms  of  ileus  and 
fecal  vomiting  are  present,  absolute  abstinence  from  food 
and  also  drink  is  necessary.  In  accordance  with  Penzoldt, 
Ewald,  and  Boas,  rectal  feeding  appears  to  me  to  be  con- 
traindicated  in  these  cases  and  the  only  way  of  supplying 
the  organism  with  nutritive  material  is  a  subcutaneous 
injection  of  saline  solutions,  sugar  solutions,  and  also  per- 
haps small  subcutaneous  injections  of  olive  oil. 

Small  pieces  of  ice  may  from  time  to  time  be  given  to 
the  p>atieut.  He  must,  however,  keep  the  ice  in  his  mouth 
until  it  melts  before  swallowing.  This  often  alleviates  the 
nausea  and  retching.  The  first  two  or  three  days  of  sick- 
ness being  over,  the  patient  may  be  allowed  to  have  milk,  an 
egg  beaten  up  in  bouillon  or  milk,  in  addition  to  the  above- 
named  food.  The  diet  should  be  kept  up  in  this  way  until 
the  pains  and  fever  have  entirely  disappeared.  At  this  pe- 
riod soft-boiled  eggs,  crackers,  small  portions  of  meat 
(squab)  or  chopped  beef  may  be  given,  and  still  later  mashed 
potatoes,  bread  and  butter,  and  light  vegetables  added. 


220  DISEASES  OP  THE  INTESTINES. 

Medicaments.  The  use  of  cathartics  is  mentioned  here 
only  in  order  to  condemn  it.  Even  injections  into  the 
bowels  should  not  be  administered  too  frequently  nor  in 
large  quantities.  A  small  enema  of  one-half  to  one  pint  of 
water  or  one-half  pint  of  olive  oil  may  occasionally  be  given. 

The  remedy  par  excellence  in  the  treatment  of  appendici- 
tis is  opium.  Its  use  was  originally  recommended  by  Eng- 
lish physicians  (Graves,  Stokes)  and  later  by  French  clin- 
icians (Petriquin,  Grisolle);  in  Germany  this  remedy 
found  a  fervent  advocate  in  Volz  and  in  America  in  Alonzo 
Clark.  During  the  last  decade  the  administration  of  opium 
has  met  with  great  opposition  especially  on  the  part  of  many 
surgeons.  Their  reasons  against  the  use  of  this  remedy  are, 
first,  that  opium  masks  the  true  picture  of  the  disease,  and 
secondly,  that  it  gives  rise  to  paralysis  of  the  intestines. 

Some  of  the  foremost  clinicians,  Nothnagel,  Penzoldt, 
Ewald,  Sahli,  Boas,  and  others,  are  even  nowadays  en- 
thusiastic admirers  of  the  opium  treatment.  The  prin- 
cipal element  of  importance  of  opium  as  a  remedy  is  its 
action  in  lessening  or  arresting  the  peristalsis  of  the  in- 
testine, and  besides  in  alleviating  i)ain.  I  myself  have 
always  used  and  still  use  the  opium  treatment  with  great 
satisfaction.  It  is  of  course  understood  that  the  opium 
should  be  given  only  in  sufficient  amount  to  allay  the  pain, 
while  excessive  doses  should  be  avoided.  As  soon  as  the 
active  stage  of  the  disease  is  passed,  the  opium  must  be 
entirely  discontinued.  The  best  way  of  administering  it 
is  that  suggested  by  Sahli .  Ten  or  fifteen  drops  of  tinc- 
ture of  opium  are  at  first  given  every  hour  until  there  is 
a  decided  subsidence  of  the  pain.  Tlien  five  to  six  drops 
are  given  every  two  or  three  hours  until  the  pains  disap- 
pear completely.  As  soon  as  there  is  an  exacerbation  an- 
other large  dose  is  administered,  but  if  the  patient  is  entirely 


APPENDICITIS.  221 

free  from  pain  uo  opium  is  given.  If  the  administration 
of  the  drug  excites  nausea  or  vomiting,  it  may  be  given  in 
the  form  of  a  sujjpository : 

IJ  Extr.  opii 0.05 

01.  theobrom , 1.00 

M.  f.  supp.    One  suppository  every  four  hours  until  subsi- 
dence of  pain. 

Or  belladonna  extract,  0.005-0.01  gm.,  may  be  added  to 
the  opium  in  the  same  suppository. 

Boas  recommends  the  administration  of  opium  subcuta- 
neously.  (Extr.  opii  aquosi  sterilis.  0.3  to  10.0  water;  1 
Pravaz  syringe  [1  gm.]  three  times  daily.) 

In  cases  in  which  the  pains  are  very  intense  and  a  quick 
action  is  desired,  morphine  may  be  administered  subcuta- 
neously  in  doses  of  gr.  ^  to  ^.  The  action  of  this  remedy 
is,  however,  not  so  satisfactory  as  that  of  opium,  as  it  has 
but  a  very  slight  influence  in  diminishing  the  peristalsis. 
When  morphine  is  used,  opium  should  be  given  in  addition. 

Poultices.  The  ajjplication  of  ice  over  the  painful  area 
is  often  beneficial  at  the  beginning  of  the  disease,  espe- 
ciall}^  if  the  temperature  is  quite  high  and  symptoms  of 
peritoneal  irritation  are  present.  If  the  patient,  however, 
complains  of  great  discomfort  from  the  api)lication  of  ice, 
it  must  1)6  discontinued.  In  the  latter  instance  a  cold 
Priessnitz  poultice  may  be  tried.  Cases  not  accompanied 
by  high  fever  often  derive  great  relief  from  the  application 
of  a  hot-water  bag  or  plain  warm  poultices.  The  latter 
are  especially  to  be  recommended  in  that  form  of  appendi- 
citis which  is  called  appendicular  colic  of  Talamon. 

Surgical  Treatmehf. — The  cjuestion  of  operation  in  ap- 
pendicitis is  a  very  live  one  nowadays  and  is  being  every- 
where discussed.  The  medical  profession  has  not  yet  come 
to  a  unanimous  conclusion  in  regard  to  it.     Surgical  treat- 


222  DISEASES  OF  THE  INTESTINES. 

ment  of  appendicitis  originated  in  this  country,  Dr.  Regi- 
nald Fitz  of  Boston  having  done  the  first  operation  for 
this  purpose,  and  it  has  been  practised  and  perfected  here 
more  than  anywhere  else.  It  is  therefore  quite  natural 
that  we  find  many  more  advocates  of  surgical  intervention  in 
America  than  abroad.  As  a  general  rule  the  majority  of  sur- 
geons frequently  recommend  operative  intervention,  while 
the  larger  number  of  physicians  reserve  -the  surgical  treat- 
ment only  for  a  small  number  of  grave  cases  of  appendicitis. 

Fowler,  Morris,  Beck,  Deaver,  Murphy,  and  others  in 
this  country  and  Legueu '  in  France  urge  surgical  treat- 
ment in  every  case  of  appendicitis.  Legueu  says :  "  Ap- 
pendicitis belongs  to  surgery."  .  .  .  "There  is  no  medi- 
cal treatment  of  appendicitis."  .  .  .  "Every  appendicitis 
must  be  operated  earlj-."  C.  Beck''  expresses  himself 
in  the  following  manner :  "  No  matter  how  mild  the  clini- 
cal picture  of  appendicitis  appears,  even  if  it  promises  a 
quick  temporary  recover^-,  the  operation  is  always  justi- 
fied. Inasmuch  as  the  gravity  of  infection  can  never  be  esti- 
mated at  the  beginning,  it  appears  wiser  to  look  upon  every 
case  of  appendicitis  as  serious.  Of  two  evils  one  should 
choose  the  lesser,  and  the  lesser  one  here  means  opera- 
tion." In  his  article  Beck  makes  the  two  following  asser- 
tions :  "  1.  Appendicitis  is  a  surgical  disease  and  should  be 
treated  surgically  as  soon  as  diagnosed.  2.  So  long  as  no 
physician  is  able  to  estimate  the  gravity  of  the  bacterial 
infection  at  the  commencement  of  the  disease  or  to  foresee 
the  course  which  the  appendicitis  will  pursue,  whether 
mild  or  grave,  the  safest  treatment  consists  in  the  early 
removal  of  the  appendix." 

'Felix  Legueu:  "Traitraent  de  I'Appendicite. "  Suite  de  Mono- 
graphies  Cliniques,  1899,  No.  80. 

^  C.  Beck  :  "Appendicitis."  Volkmann's  Sammlung  klinischer  Vor- 
trage,  No.  221,  Sept..  1898. 


APPENDICITIS.  223 

Many  surgeons,  even  in  this  country,  however,  do  not 
take  so  radical  a  view  as  the  above  writers.  Thus  Willy 
Meyer,'  Charles  McBurney,  W.  T.  Bull,  A.  J.  McCosh  and 
F.  Hawkes,"  and  others  do  not  recommend  the  early  opera- 
tion in  milder  forms  of  appendicitis.  McCosh  and  Hawkes 
express  themselves  in  the  following  manner  with  regard  to 
the  necessity  of  operative  interference :  "  When  the  presence 
of  pus  is  assured,  the  sooner  operation  is  done  the  better. 
Also  there  are  cases  which  begin  and  continue  for  twenty - 
four  or  forty-eight  hours  with  such  severity  that  a  judicious 
mind  must  conclude  that  operation  is  demanded.  So  in  the 
chronic  and  relapsing  cases  where  the  symptoms  have  con- 
tinued for  months  with  such  severity  and  have  recurred 
so  frequently  as  to  subject  the  patient  to  a  life  of  semi-in- 
validism,  no  wise  surgeon  can  counsel  any  other  plan  of 
treatment  than  removal  of  the  diseased  appendix.  Likewise 
when  the  patient  has  suffered  from  three  or  more  attacks 
the  offending  organ  should  be  removed,  for  other  attacks 
will  in  all  probability  follow.  The  same  indication  for 
operation  also  exists  in  our  opinion  if  a  patient  hias  suf- 
fered from  two  attacks  within  a  year  or  even  two  years." 
..."  The  view  which  we  take  is  that  operation  is  not 
necessary  in  every  case  of  appendicitis.  We  believe  that 
not  infrequently  patients  recover,  and  recover  permanently, 
from  one  attack  of  appendicitis,  and  that  in  a  certain  num- 
ber of  cases,  provided  a  careful  watch  is  kept,  operation  is 
not  necessary.  On  the  other  hand,  we  acknowledge  that 
many  cases  which  did  not  appear  to  be  serious  have  been 
allowed  to  die  when  they  might  have  been  saved  by  opera- 
tion." 

'  Willy  Meyer  :  "  When  Shall  we  Operate  for  Appendicitis?  "    Medi- 
cal Record,  February  29.  1896. 

'  A.  J.  McCosh  and  F.  Hawkes  :  "  The  Surgical  Treatment  for  Appen- 
dicitis."   The  American  Journal  of  the  Medical  Sciences,  May,  1897. 


224  DISEASES  OF  THE  INTESTINES. 

Willy  Meyer,  who  was  among  the  first  to  recommend 
the  removal  of  the  appendix  during  the  free  interval,  comes 
to  the  following  conclusions  in  his  paper  already  men- 
tioned: "1.  In  case  of  diffuse  perforative  appendicitis  the 
operation  must  always  be  done  at  once.  2.  In  cases  of 
acute  ai)pendicitis  the  patient  always  needs  careful  obser- 
vation. If  the  pulse  goes  above  116  and  120  and  has  a 
tendency  to  stay  there,  the  indication  for  an  operation  is 
given.  In  cases  of  doubt  the  operation  is  better  than 
waiting.  In  cases  of  subacute  attacks  of  api^endicitis,  also 
after  the  first  severe  attack  from  w  hich  the  patient  recovers 
without  immediate  operation,  the  appendix  should  be  re- 
moved. The  appendix  once  inflamed  has  to  be  looked  upon 
as  a  diseased  organ  which  is  very  apt  to  give  repeated  and 
more  serious,  even  fatal,  trouble  in  the  future." 

Among  the  German  surgeons  Sonnenburg,  and  especially 
Riedel, '  are  advocates  of  early  surgical  intervention  in  the 
grave  forms  of  appendicitis.  Riedel  says :  "  As  soon  as  the 
temperature  reaches  101°,  the  pulse  100,  the  immediate 
removal  of  the  appendix  is  indicated.  ...  A  tumor  which 
has  developed,  accompanied  by  fever  and  an  acceleration 
of  the  pulse,  is  always  an  indication  for  immediate  opera- 
tion." R.  Stein ''  and  Henry  J.  Wolf,'  in  papers  read  quite 
recently  before  the  German  Medical  Society  of  New  York, 
urged  early  surgical  intervention  in  all  the  graver  forms 
of  appendicitis. 

With  Penzoldt,  Nothnagel,  Ewald,  Boas,  and  others  I 
would  give  the  following  indications  for  surgical  interven- 
tion in  this  disease : 

'Riedel:  "Ueber  die  sog.  Frllhoperation  bei  Appendicitis  puru 
leDta  resp.  gangraenosa. "  Berliner  klinische  Wocbenschrift,  1899, 
33  und  34. 

*  R.  Stein  :  Deutsche  med.  Wochenschr. .  1899,  p.  440. 

'H.  J.  Wolf:  New  Yorker  raedicinische  Monatsschrift,  1899. 


APPENDICITIS.  225 

1.  Diffuse  peritonitis  in  consequence  of  perforation  of 
the  appendix  demands  immediate  operation.  As  a  rule  the 
following  symptoms  will  be  found :  Sunken  and  drawn  fea- 
tures, cyanosis,  a  small  and  very  frequent  pulse,  an  increase 
of  the  painful  area,  often  also  a  bloated  condition  of  the 
abdomen. 

2.  Whenever  an  appendicular  abscess  showing  fluctua- 
tion is  present,  an  operation  should  be  performed. 

3.  If  the  protracted  course  of  the  disease  points  to  the 
existence  of  an  abscess,  giving  rise  to  slight  septic  symp- 
toms, an  operation  should  be  undertaken. 

While  in  these  three  groups  there  can  be  no  hesita- 
tion in  recommending  the  operation,  in  the  following 
groups  the  necessity  of  surgical  intervention  must  be  con- 
sidered and  decided  in  each  individual  case. 

4.  (o)  If  the  rational  treatment  does  not  produce  any  im- 
provement in  the  course  of  three  to  five  days,  the  symptoms 
persisting  in  undiminished  severity  or  becoming  even  more 
pronounced,  an  operation  may  be  resorted  to.  (b)  A  sud- 
den rise  of  temperature  lasting  over  twenty-four  hours, 
after  the  first  few  days  of  sickness,  is  also  an  indication  for 
operation,  (c)  A  very  frequent  pulse,  not  corresponding 
to  the  degree  of  fever,  is  another  symptom  which  justifies 
the  consideration  of  an  operation,  (c?)  If  the  tumor  con- 
tinues to  increase  in  size  after  the  fifth  day  of  sickness,  an 
operative  treatment  should  be  considered. 

5.  The  removal  of  the  appendix  should  be  undertaken: 
(a)  In  all  cases  of  ajipendicitis  in  which  after  recovery  the 
pain  in  the  right  iliac  region  persists  for  a  long  time  (sev- 
eral months) ;  (b)  in  recurrent  appendicitis  if  the  attacks 
have  been  quite  severe  or  if  they  have  followed  each  other 

at  short  intervals.  * 

15 


CHAPTER  IX. 

INTESTINAL  OBSTRUCTION. 

{Acute  and  Chronic.) 

Introductory  Remarks. — By  intestinal  obstruction  is  un- 
derstood a  great  variety  of  conditions  which,  although 
unlike  in  character,  have  yet  the  common  feature  of  me- 
chanically causing  an  obstruction  to  the  passage  of  con- 
tents along  the  intestine.  Leichtenstern  '  distinguishes  the 
following  three  groups  with  regard  to  the  causation  of  the- 
intestinal  obstruction : 

1.  Occlusion*  due  to  pressure  from  without  or  com- 
pression of  the  intestinal  lumen  in  the  full  sense  of  the 
word.  To  this  group  belong  incarcerations  of  the  intes- 
tines in  apertures,  in  slits,  and  in  hernial  openings; 
strangulation  by  pseudo-ligaments,  the  vermiform  proc- 
ess, and  diverticula;  compression  by  tumors,  by  the  mes- 
entery, or  by  displaced  abdominal  organs.  Eotations  of 
the  intestinal  tube  aroimd  iis  axis  (torsions)  and  forma- 
tion of  knots  also  belong  to  this  category. 

2.  Occlusion  from  within  the  intestinal  lumen  (obtura- 
tion). The  obturation  may  be  i^roduced  either  by  gall 
stones,  enteroliths,  foreign  bodies,  hai'dened  fecal  masses, 
or  by  neoplasms  of  considerable  size,  especially  polypi. 
Intussusception  (involution  of  ohq  coil  of  the  bowel  into 
another)  also  belongs  to  this  class. 

'  Leichtenstern  :  "  Verengerungen,  Verschliessungen  und  Lagever- 
anderungen  des  Darms."  Zierassen's  "  Handbuch  der  speciellen  Patho- 
logic und  Tlierapie, "  Bd.  vii..  Leipzig,  1878. 


ACUTE  OBSTRUCTION.  227 

3.  Occlusious  which  originate  from  factors  within  the 
intestinal  wall  and  causing  narrowing  of  the  lumen  either 
directly  or  indirectly.  Constriction  may  occur  either  in 
circular  form  (strictures)  or  as  a  result  of  flexions.  Ob- 
structions developing  after  chronic  peritonitis,  distortions, 
and  angular  bends  of  the  intestine,  cicatricial  stenoses 
as  well  as  those  produced  by  neoplasms,  belong  to  this 
class. 

Notwithstanding  the  diversity  and  great  multiplicity  of 
the  anatomical  factors  causing  stenoses  and  obstructions  of 
the  intestines,  the  clinical  picture  and  the  consecutive  le- 
sions which  they  evoke  greatly  resemble  each  other.  It 
will  therefore  perhaps  be  practical  to  give  first  the  clinical 
picture  of  complete  obstruction  of  the  bowels  (ileus)  and 
of  stenosis  of  the  intestine,  and  then  to  discuss  the  diflfer- 
ent  anatomical  causes  and  also  the  differential  diagnosis. 

ACUTE  INTESTINAL  OBSTRUCTION. 

Synonyms. — Ileus,  miserere,  passio  iliaca. 

Definition. — An  acute  stoppage  of  the  passage  of  the  in- 
testinal contents.  This  may  be  caused  either  by  a  me- 
chanical occlusion  at  a  certain  part  of  the  intestinal  canal 
(mechanical  ileus)  or  by  an  entire  absence  of  motor  power 
in  a  portion  of  the  bowel  (dynamic  or  paralytic  ileus)  or 
sometimes  by  both  (mechano-dynamic  ileus). 

Etiology.— The  etiology  of  ileus  is  quite  complicated, 
and  it  will  be  best  to  analyze  separately  the  different  factors 
producing  it. 

Compression  of  the  Intestines.  Compression  of  the  in- 
testines can  occur :  (1)  by  strangulation  through  adhesions, 
bends  or  pseudo-ligaments,  by  Meckel's  diverticulum,  by 
normal  structures  abnormally  attached,  by  slits  and  aper- 


228  DISEASES  OF  THE  INTESTINES. 

tures  in  the  mesentery  and  omentum,  and  by  incarcerations 
into  hernise;  (2)  by  torsions  (volvulus) ;  and  (3)  by  tumors 
from  without. 

The  primary  factor  in  jiroducing  isolated  adhesions 
(bands  or  pseudo-ligaments)  is  a  preceding  localized  peri- 
tonitis. In  some  cases  these  bands  may  have  been  con- 
genital and  due  to  intra-uterine  peritonitis.  The  band 
may  have  the  form  of  a  firm  fibrous  cord  or  it  may  be  very 
slender  and  may  appear  as  a  tough,  rigid  thread.  Occa- 
sionally it  may  be  of  comparatively  large  size.  Seldom 
the  constricting  ligament  has  the  appearance  of  an  actual 
band,  having  a  width  of  half  an  inch  or  more. 

The  strangulation  of  the  intestine  by  an  isolated  peritoneal 
adhesion  takes  place  in  two  ways :  first,  the  intestine  may 
be  strangulated  under  the  band  as  beneath  a  shallow  and 
narrow  arch;  secondly,  it  may  become  snared  and  con- 
stricted by  a  noose  or  knot  formed  by  the  false  ligament 
itself.  Strangulation  from  bands  occurs  when  these  are  com- 
paratively short  and  tightly  stretched  over  a  firm  surface. 
The  arch  beneath  which  the  implicated  bowel  passes  is 
usually  large  enough  to  admit  one  to  three  fingers.  Stran- 
gulation by  a  noose  or  knot  requires  the  presence  of  a  long 
false  ligament  which  must  lie  loose  and  free  in  the  abdom- 
inal cavity,  being  attached  only  at  its  two  ends.  The  most 
common  way  in  which  a  coil  of  intestine  becomes  snared 
is  where  a  lax  band  forms  a  ring  or  spiral  between  its  fixed 
points.  Through  this  ring  a  loop  of  the  small  intestine 
slips ;  the  protrusion  becoming  larger  the  implicated  coil 
cannot  free  itself  from   the  noose  and  is  strangulated. 

Strangulation  by  the  formation  of  a  knot  is  described  by 
Leichtenstern  in  the  following  manner :  "  There  are  several 
kinds  of  this  knotting.  The  most  frequent  is  the  follow- 
ing :  A  long  and  loose  ligament  is  fastened  at  one  end  to 


ACUTE  OBSTRUCTION. 


229 


a  loop  of  the  small  intestine,  and  hangs  in  the  form  of  a 
simple  coil  (Fig.  29);  if  the  top  of  the  intestinal  loop 
passes  directly  through  the  coil  a  simple  knot  is  formed 
about  the  piece  of  the  intestine,  as  is  shown  in  Fig.  30. 
It  is  evident  that  the  same  result  can  be  produced  by  the 


FlG.  31. 


FIG.  32.  Fl«-  29. 

Figs.  28-32.— Types  of  Constricting  PeritonlOc  Bands.   (After  Lelchtenstem  and  Treyes.) 

coil  being  drawn  over  the  top  of  and  around  the  intestinal 
loop.  Another  and  rarer  form  of  knot  is  produced  as  fol- 
lows :  A  long  and  perfectly  loose  false  ligament  forms  a 
simple  coil  between  its  points  of  attachment.  If  now  one 
leg  of  the  so-called  primary  noose  passes  through  it  we 
have  a  knot  like  that  shown  in  Fig.  31,  and  if  now  the 


230  DISEASES  OF  THE  INTESTINES. 

intestinal  loop  passes  directly  through  (Fig.  32),  it  be- 
comes firmly  caught  and  strangulated.  A  common  char- 
acteristic of  all  described  knots  is  that  when  the  strangu- 
lated intestine  is  freed,  the  ligament  can  immediately  be 
drawn  out  straight." 

Strangulation  by  MeckeVs  Diverticulum.  Meckel's  diver- 
ticulum is  due  to  the  persistence  or  incomplete  oblitera- 
tion of  the  vitelline  duct.  Most  commonly  it  exists  as  a 
blind  tube,  given  oflf  from  the  ileum.  Its  length  is  about 
three  inches.  As  a  rule,  it  is  cylindrical  in  shape,  with  a 
conical  extremity.  Occasionally  it  presents  a  globular 
shape  and  is  then  called  "clubbed."  Meckel's  diverticle 
is  always  single  and  is  attached  to  the  ileum  one  to  three 
feet  above  the  ileo-cgecal  valve.  As  a  rule,  the  end  of  the 
diverticulum  is  free.  In  some  instances  it  is  attached  to 
the  umbilicus  or  to  the  abdominal  wall.  Sometimes  the 
end  attached  to  the  abdominal  parietes  may  give  way  and 
form  fresh  adhesions  with  some  points  of  the  peritoneal 
surface.  The  latter  occurrence  is  of  great  importance  with 
reference  to  strangulation  of  the  intestine,  which  frequently 
takes  place  under  these  conditions.  By  means  of  the  new 
adhesion  of  the  diverticulum  a  loop  is  formed  in  which 
some  portion  of  the  intestine  is  liable  to  engage.  Another 
possibility  for  strangulation  by  the  diverticulum  is  afforded 
when  its  end  is  free  and  club-shaped.  The  diverticulum 
forms  a  ring  into  which  its  own  free  end  projects.  A  looj) 
of  the  intestine  entering  the  centre  of  this  ring  may  push 
the  clubbed  end  of  the  process  before  it  and  so  tie  the 
knot,  thus  leading  to  obstruction.  Again  the  diverticulum 
may  surround  the  pedicle  of  an  intestinal  loop  in  such  a 
way  as  to  encircle  it  with  a  single  knot  (see  Figs.  33,  34,  35). 

In  a  similar  manner  as  Meckel's  diverticulum  some  nor- 
mal structures  may  act  when  they  are  abnormally  attached. 


ACUTE  OBSTRUCTION. 


231 


Thus  the  vermiform  appendix  may  become  adherent  to 
some  point  of  the  neighboring  peritoneum  and  so  form  an 
arch  under  which 

a  loop  of  the  in-  ^'<*-  ^  ^  '»«•  3*- 

testine  msiy  h  e 
strangulated. 
The  Fallopian 
tube  may  likewise 
become  adherent 
to  the  adjacent 
peritoneum  situ- 
ated in  the  iliac 
fossa  and  thus 
form  an  arch  in- 
to which  a  por- 
tion of  the  intes- 
tine may  slip  and 
become  incarcer- 
ated. Other  in- 
ternal organs  ab- 
normally  at- 
tached may  form 
similar  traps  for 
intestinal  stran- 
gulation. 

Of  great  clini- 
cal importance  is 
the  strangulation 

of  the  intestine  in  slits  and  apertures  of  the  mesentery  or 
omentum.  These  may  be  either  congenital  or  of  traumatic 
origin.  Similar  to  the  action  of  slits  in  the  production 
of  strangulation  are  also  tlie  various  internal  hernise  (her- 
nia duodeno-jejunalis,  hernia  retroperitouealis   anterior, 


no.  35.   • 

Figs.  33-35.— Knotting  of  a  Meckel's  Diverticulum  which 
has  a  Button-like  Swelling  of  its  Extremity.    (Treves.) 


232  DISEASES  OP  THE  INTESTINES. 

hernia  intrasigmoida,  hernia  bursaB  omentalis,  formed 
by  the  foramen  of  Winslow,  diaphragmatic  hernia). 

In  all  these  cases  the  mechanism  of  the  obstruction  is  as 
follows :  A  coil  of  gut  may  be  driven  with  sudden  severe 
force  beneath  the  band  or  through  an  aperture  and  become 
practically  strangulated  at  once,  as  is  often  the  case  in 
strangulated  hernia.  There  being  no  natural  force  to  drive 
the  coil  out  of  its  place  of  imprisonment,  it  remains  firmly 
gripped.  In  other  cases  the  involved  intestine  may  not  be 
strangulated  at  first,  but  the  band  pressing  upon  the  mes- 
enteric vessels  produces  a  congestion  in  the  implicated 
coils,  which  become  engorged  and  distended  by  an  in- 
creased accumulation  of  gas,  and  thus  complete  strangu- 
lation is  the  result.  In  other  cases,  again,  the  final  cause 
of  a  strangulation  is  a  twisting  of  the  bowel.  All  the  va- 
rieties of  intestinal  strangulation  just  mentioned  occur  in 
the  small  intestine,  the  lower  portion  of  the  ileum  being 
principally  aflfected,  less  frequently  its  upper  portion  or 
the  jejunum. 

The  occlusion  may  in  some  cases  be  due  to  kinking  of 
the  intestine  through  a  band  attached  to  the  bowel  and 
dragging  upon  it.  Adhesions  may  also  obstruct  the  bowel, 
compressing  its  lumen.  This  occurs  when  false  mem- 
branes are  situated  around  the  bowel  and  have  undergone 
shrinking.  They  then  compress  the  intestine  seriously 
and  narrow  its  lumen.  The  same  i)rocess  of  shrinking 
may  also  effect  an  obstruction  of  the  bowel  if  it  takes 
place  in  the  mesentery  after  inflammation. 

Volvulus.  By  the  term  volvulus  is  understood  an  obstruc- 
tion of  the  bowel  by  a  twist  about  its  mesentery,  or  its  own 
axis,  or  the  intertwining  of  an  intestinal  coil  within  another. 
Twisting  of  the  bowel  occurs  most  often  in  the  sigmoid 
flexure.     The  usual  cause  of  this  trouble  is  chronic  consti- 


ACUTE  OBSTRUCTION.  233 

pation,  for  in  this  condition  the  flexure  fs  more  or  less 
constantly  distended.  Its  walls  become  partly  paralyzed 
and  hang  down  into  the  pelvis,  like  an  inert  heavy  mass, 
being  filled  with  fecal  matter.  Traction  is  thereby  exerted 
upon  the  mesocolon  and  a  loop  is  soon  formed.  A  twist- 
ing of  the  latter  is  brought  about  either  by  some  displace- 
ment of  the  bowel  or  by  a  sudden  change  in  the  position 
of  the  body.  The  ascending  colon,  caecum,  and  the  small 
intestine  may  also  be  affected  in  the  same  manner,  al- 
though less  frequently.  Intertwining  of  the  intestine  is 
here  more  often  met  with. 

Obturations  of  the  Intestine.  Intestinal  occlusion  often 
takes  place  in  consequence  of  obturation  of  the  lumen  of 
the  gut  through  foreign  bodies  lodging  therein.  Accumu- 
lations of  fecal  matter  may  give  rise  to  such  an  occurrence. 
The  hard  fecal  tumor  is  then  situated  either  in  the  caecum 
or  in  the  colic  or  sigmoid  flexures.  In  these  cases  chronic 
constipation  has  existed  for  a  long  time. 

Gall  stones,  although  rarely,  give  rise  to  intestinal  oc- 
clusion. In  order  to  do  this  they  must  be  of  considerable 
size.  "  The  puzzle  as  to  how  the  camel  could  go  through 
the  eye  of  the  needle,  i.e.,  how  these  enormous  gall  stones 
could  reach  the  bowel,  has  been  solved,  by  the  assumption 
on  fair  evidence  that  an  ulcerative  process  opens  the  way 
from  the  gall  bladder  to  the  bowel,  though  doubtless  very 
large  stones  occasionally  find  their  passage  through  the 
ducts"  (E.  D.  Ferguson'). 

In  a  similar  manner  enteroliths  may  also  cause  obstruc- 
tion of  the  bowel.  This  happens  especially  if  an  entero- 
lith situated  in  an  intestinal  diverticulum  has  been  dis- 
lodged and  found  its  way  into  the  canal  of  the  gut. 

1  E.  D.  Ferguson :  Transactions  of  the  New  York  State  Medical 
Association,  1898,  p.  233. 


234  DISEASES  OF  THE  INTESTINES. 

Foreign  bodies  which  have  been  accidentally  or  inten- 
tionally swallowed  may  under  favorable  conditions  reach 
some  part  of  the  bowel  and  here  obstruct  the  lumen.  This 
will  occur  if  the  foreign  body  is  of  considerable  size,  or  if 
it  is  not  smooth  but  provided  with  sharp  points.  The 
latter  catch  in  a  fold  of  mucous  membrane  and  prevent  its 
further  passage.  The  most  varied  substances  have  thus 
been  found  to  be  the  cause  of  intestinal  obstruction :  mar- 
bles, stones,  coins,  glass  stoppers,  corks,  spoons,  knives, 
forks,  keys,  needles,  pins,  buttons,  false  teeth  with  the 
plate.  Kernels  of  fruit  like  cherries,  prunes,  etc.,  may 
accumulate  in  the  bowel  and  by  means  of  fecal  matter  be 
kept  together,  forming  a  large  conglomeration,  completely 
obstructing  the  canal. 

Recently  Murphy's  button  has  also  been  found  in  a  few 
instances  to  cause  obstruction  of  the  bowel. 

Intestinal  parasites  (taj^eworms,  ascaris  lumbricoides) ,  if 
present  in  large  numbers,  ma}'  also  form  a  mass  obstruct- 
ing the  canal.  This  occurs  especially  after  a  vermifuge 
has  been  administered  and  the  dead  parasites  have  re- 
mained within  the  canal. 

Similar  to  the  action  of  foreign  bodies  are  also  tumors 
{polypi,  fibroma,  myoma,  etc.)  connected  by  a  pedicle 
with  the  intestinal  wall,  filling  up  its  lumen. 

Intussusception.  Intussusception  or  invagination  means 
the  prolapse  of  one  part  of  the  intestine  into  the  lumen  of 
an  immediately  adjoining  part.  An  intussusception  shows 
in  a  vertical  section  six  layers  of  intestine,  three  on  either 
side  of  the  central  canal,  which  are  more  or  less  parallel  to 
one  another.  The  arrangement  of  the  layers  is  such  that 
mucous  membrane  is  in  contact  with  mucous  membrane,  and 
peritoneum  with  peritoneum.  On  transverse  section  the 
invaginated  mass  shows  three  concentric  rings  of  bowel. 


ACUTE  OBSTRUCTION.  236 

The  external  of  the  three  layers  is  called  the  intussusci- 
piens,  the  sheatli,  or  the  receiving  layer.  The  innermost 
cylinder  is  called  the  entering  layer  and  the  middle  one  the 
returning  layer.  The  latter  two  together  form  the  intus- 
susceptum.  The  neck  of  the  intussusceptum  is  at  its  up- 
per part  where  the  returning  layer  joins  the  sheath. 

In  case  the  intussusception  lasts  for  some  time  the  se- 
rous surfaces  of  the  gut  touching  each  other  ma}'  become 
glued  together  and  ultimatelj'  adherent.  This  will  prevent 
the  disengagement  of  the  invaginated  portion,  while  its  fur- 
ther passage  into  the  other  bowel  will  not  be  interfered 
with.  The  mesentery  always  participates  in  the  invagina- 
tion and  becomes  more  or  less  compressed  and  wedged  in 
by  the  sheath.  The  whole  mass  of  a  simple  intussuscep- 
tion may  in  its  turn  become  invaginated  and  give  five  in- 
stead of  three  coats,  or  even  seven  if  the  process  is  re- 
peated, so  that  the  upper  edge  of  the  intussuscipiens  is 
rolled  over  like  a  cuff.  These  double  and  triple  intussus- 
ceptions are  comparatively  rare. 

With  regard  to  the  mechanism  of  intussusception  Noth- 
nagel's  experiments  on  animals  have  proven  of  greatest 
value.  According  to  this  writer  intussusception  may  be 
due  either  to  a  localized  spastic  contraction  of  a  portion 
of  the  bowel  or  to  a  total  paralysis.  The  normal  gut  im- 
mediateh'  below  the  contracted  part  slips  upward  to  a  slight 
extent  over  this  strongly  contracted  and  greatly  narrowed 
portion,  and  invagination  is  thus  produced.  Again  if  a 
segment  of  the  bowel  is  paralyzed,  the  gut  lying  immedi- 
ately below  it,  on  contraction  will  slip  into  the  paralyzed 
portion  and  thus  an  invagination  may  arise. 

Intussusception  may  take  place  at  any  point  within  the 
entire  small  and  large  intestines.  Over  Mty  per  cent  of 
the  cases  consist  of  the  invagination  of  the  ileum  into  the 


236  DISEASES  OF  THE  INTESTINES. 

colon.  With  regard  to  the  remote  cause  of  intussuscep- 
tion Treves  '  has  examined  a  number  of  reported  cases  and 
found  it  in  one  hundred  examples  of  intussusception  dis- 
tributed as  follows : 

1.  No  evident  exciting  cause 62  per  cent. 

2.  Diarrhoea,  dysentery,  enteritis,  marked  irregularity  of 

the  bowels 8  * 

3.  Polypi 5  •• 

4.  Ingesta 5  ** 

5.  Injuries  and  exposure  to  cold 5  ** 

6.  Certain  acute  and  chronic  ailments  which  may  or  may 

not  have  bad  a  concern  in  the  etiology,  such  as 
typhoid  fever,  whooping-cough,  measles,  scarlet 
fever,  smallpox,  cholera,  and  hernia ;  with  these 
may  be  included  pregnancy  and  labor 15       * 

Total 100       " 

This  clinical  form  of  intussusception  must  not  be  con- 
founded with  agonal  intussusception,  which,  as  the  term 
indicates,  occurs  shortly  before  death  and  is  purely  of 
anatomical  importance.  The  agonal  form  of  intussuscep- 
tion is  sometimes  found  multiple  and  is  met  with  fre- 
quently at  autopsies  of  children  who  have  died  from  affec- 
tions of  the  brain. 

Pathological  Clianges. — The  lesions  which  are  encountered 
in  acute  ileus,  no  matter  what  be  its  origin,  are  the  follow- 
ing: The  intestinal  coils  above  the  occluded  part  of  the 
bowels  present  a  quite  different  appearance  from  those 
below.  The  former  are  distended,  filled  with  gas  and  ill- 
smelling  feculent  contents;  and  this  ectatic  condition  is 
the  more  pronounced  the  nearer  they  are  situated  to  the 
occluded  part.  If  the  occlusion  lies  in  the  jejunum  or 
ileum,  the  distention  will  involve  the  entire  upper  portion 
of  the  small  intestine  and  also  the  stomach.  If,  however, 
the  stoppage  is  situated  within  the  colon,  the  dilatation 
'  Treves:  "Intestinal  Obstruction,"  p.  211. 


ACUTE  OBSTRUCTION.  237 

will  at  first  occupy  that  portion  of  the  colon  situated  be- 
tween the  ileocsBcal  valve  and  the  obtruded  spot,  while 
the  small  intestine  may  remain  unchanged,  the  ileocaecal 
valve  acting  in  its  usual  way  and  thus  preventing  an  over- 
flow of  the  contents  of  the  colon  into  the  small  intestine. 
Under  such  circumstances  the  dilated  portion  of  the  colon 
may  attain  considerable  size,  resembling  almost  the  stom- 
ach. After  the  condition  has  lasted  a  few  days,  however, 
the  ileocaecal  valve  ceases  to  functionate  and  now  the  con- 
tents of  the  colon  overflow  the  small  intestine  and  the 
stomach  and  these  organs  become  also  overfilled  and  dis- 
tended. The  portion  of  the  intestine  situated  below  the 
occlusion  is  empty  and  contracted. 

The  intestinal  coils  above  the  occluded  spot  are  usually 
engaged  in  very  active  peristaltic  movements,  which  repre- 
sent an  attempt  of  nature  to  overcome  the  obstacle.  After 
these  peristaltic  motions  have  lasted  a  few  days,  a  paralytic 
state  of  the  intestines  supervenes. 

The  intestinal  mucosa  situated  near  the  occlusion  is 
subjected  to  great  mechanical  and  chemical  irritations 
due  to  the  constant  presence  of  considerable  amounts  of 
decomposed  material,  and  thus  grows  intensely  inflamed. 
Often  ulcers  develop  which  may  penetrate  the  wall  of 
the  bowel  and  cause  fatal  peritonitis.  In  rare  instances 
after  such  a  perforation,  adhesion  to  neighboring  intes- 
tinal coils  may  occur  and  give  rise  to  fecal  abscesses 
and  abnormal  communications  between  different  intestinal 
segments.  By  means  of  a  similar  process  an  opening  may 
be  established  between  the  intestine  and  the  abdominal 
walls  in  such  a  manner  that  the  fecal  matter  finds  an  exit 
here  (anus  praeternaturalis). 

Localized  or  general  jieritonitis  is  thus  often  present  in 
cases  of  intestinal  obstruction.     Serous,  bloody,  or  puru- 


238  DISEASES  OF  THE  INTESTINES. 

lent  exudation  is  frequently  found  in  the  abdominal  cav- 
ity. The  anatomical  lesions  are  most  pronounced  in  the 
immediate  vicinity  of  the  occluded  intestine.  This  is  due 
not  only  to  the  stoppage  of  the  intestinal  contents  but  also 
to  interference  with  the  circulation  of  the  gut  produced  by 
the  same  factors  which  have  caused  the  obstruction.  Nu- 
merous large  and  small  mesenteric  veins  become  com- 
pressed, thus  causing  congestion  and  hemorrhages.  The 
intestinal  walls  appear  infiltrated  with  blood,  showing  ec- 
chymoses  at  various  places,  and  may  even  appear  dark 
red.  In  the  neighborhood  of  the  occlusion  the  intestine 
may  be  covered  with  black  curdled  blood  in  the  form  of 
a  membrane.     Its  walls  become  brittle  and  gangrenous. 

Symptomatology.— 'Yhe  symptoms  of  acute  intestinal  ob- 
struction appear  either  suddenly  6r  after  slight  disturb- 
ances have  existed  for  a  few  days,  as  for  instance  diar- 
rhoea, constipation,  feeling  of  uneasiness.  In  some 
instances  the  history  of  an  exciting  cause  is  given.  Thus 
a  severe  blow  on  the  abdomen,  violent  bodily  exertion,  a 
cold,  a  too  copious  meal,  or  a  strong  laxative. 

The  patients  are  first  seized  with  violent  abdominal 
pains,  sometimes  of  a  crampy  character.  The  pain  may 
be  felt  at  first  at  a  certain  definite  spot  within  the  abdo- 
men, while  later  it  becomes  more  diffuse.  In  other  in- 
stances the  patient  is  unable  to  localize  the  pains  dis- 
tinctly. Occasionally  the  area  around  the  navel  is  given 
as  the  seat  of  the  pains,  while  in  other  cases  they  are  re- 
ferred to  the  entire  abdomen.  The  pain  usually  exists  un- 
interniptedly,  though  it  may  show  exacerbations  from  time 
to  time.  Soon  after  the  occurrence  of  these  colicky  pains 
eructations  of  gas  and  then  vomiting  appear.  At  the  be- 
ginning gastric  contents  are  ejected,  later  bile,  and  finally 
offensive  feculent  material  is  brought  up.     The  latter  usu- 


ACUTE  OBSTRUCTION.  239 

ally  has  a  yellowish-brown  color,  is  liquid,  and  contains 
only  very  fine,  small,  solid  particles  suspended  in  the  fluid. 
At  this  period  the  eructated  gases  have  a  fetid  odor  and 
hiccough  almost  constantly  distresses  the  patient.  After 
the  act  of  vomiting  the  patient  may  feel  somewhat  relieved 
for  a  short  while,  but  soon  there  is  a  return  of  the  severe 
symptoms. 

Almost  simultaneously  with  vomiting,  meteorism  of  the 
abdomen  ensues.  The  passage  from  the  rectum  is  entirely 
stopped  and  there  is  no  evacuation  either  of  fecal  matter 
or  of  flatus.  The  meteorism  may  involve  either  a  certain 
region  of  the  abdomen  or  the  entire  cavity.  The  tj^mpani- 
tes  gradually  increases  and  a  feeling  of  tension  becomes 
more  and  more  pronounced.  The  diaphragm  is  soon 
pushed  upward  by  intestinal  coils  filled  with  gas  in  such 
a  manner  that  the  liver  dulness  may  be  absent  from  the 
entire  right  thoracic  cavity.  Dyspnoea  supervenes;  the 
breathing  becomes  accelerated  and  superficial,  assuming 
the  thoracic  type.  The  pulse  is  small  and  frequent.  The 
extremities  are  cold,  the  skin  is  covered  with  perspiration, 
the  face  is  pale,  bearing  the  expression  of  utmost  anguish, 
the  eyes  are  sunken,  dryness  of  ihe  throat  and  extreme 
thirst  exist,  and  the  patient  is  barely  able  to  use  his  voice. 
These  extremely  painful  and  tormenting  symptoms  persist 
and  the  patient  succumbs — unless  there  is  a  change  in  the 
course  of  the  disease — remaining  conscious  until  the  end. 

After  having  given  a  general  description  of  the  clinical 
picture  of  ileus  it  will  not  be  amiss  to  discuss  each  symp- 
tom separately. 

1.  Pains.  Pain,  the  most  constant  and  conspicuous 
symptom  of  intestinal  obstruction,  depends  upon  several 
conditions.  It  is  usually  due,  first,  to  the  injury  inflicted 
on  the  peritoneum  and  the  intestinal  walls  in  consequence 


240  DISEASES  OF  THE  INTESTINES. 

of  the  strangulation;  secondly,  especially  at  a  somewhat 
later  period,  to  the  tumultuous  and  increased  irregular 
peristaltic  movement  of  the  intestines.  These  movements 
above  the  site  of  obstruction  are  of  a  very  intense  charac- 
ter and  produce  "  colic  "  as  virell  as  exacerbations  of  the 
pains  which  occur  at  certain  intervals.  The  intensity  of 
the  pain  depends  upon  the  degree  of  excitability  of  the 
individual,  upon  the  state  of  the  sensorium,  upon  the  ex- 
tent of  the  intestine  and  peritoneum  involved,  and  upon 
the  severity  of  the  occluding  lesion  and  the  rapidity  of  its 
occurrence.  Later  on  the  pain  is  influenced  by  the  dis- 
tention of  the  gut  and  by  the  presence  or  absence  of  peri- 
tonitis. 

At  the  commencement  of  the  disease  the  pain  is  fre- 
quently not  aggravated  and  sometimes  relieved  by  press- 
ure. Later,  however,  the  pain  is  considerably  increased 
by  even  slight  pressure,  the  cause  of  this  being  the  pres- 
ence of  peritonitis. 

According  to  Treves,'  the  pain  is  constant,  although 
liable  to  periodical  exacerbations  in  cases  of  complete  ob- 
struction. In  cases  in  which  the  obstruction  is  but  par- 
tial the  pain  is  distinctly  intermittent,  and  the  patient 
experiences  intervals  between  attacks  of  pains  during  which 
he  is  free  from  suffering.  The  pain  as  a  rule  grows  more 
intense  with  the  progress  of  the  disease.  There  may  be, 
however,  a  diminution  in  the  severity  of  the  pain  for  a  short 
period  before  a  fatal  issue,  caused  by  a  collapse,  paralysis 
of  the  intestine,  rupture  or  perforation  of  the  bowel,  or  by 
a  diminished  activity  of  the  sensorium. 

Treves  has  pointed  out  that  no  matter  in  what  part  of  the 
small  intestine  the  obstruction  is  situated,  the  pain  arising 
therefrom  is  usually  referred  to  the  region  of  the  umbilicus. 
'F.  Treves:  "Intestinal  Obstruction,"  Pliiiadelphia,  1884. 


ACUTE  OBSTRUCTION.  241 

If  the  obstruction  is  localized  in  the  large  bowel,  then  the 
pain  may  be  experienced,  especially  at  the  beginning  of 
the  disease,  at  the  seat  of  the  lesion  j  later,  however,  the 
pain  may  assume  a  more  diffused  character  or  may  be  fait 
at  other  regions  of  the  abdomen.  This  is  the  reason  why 
only  the  initial  jjain  is  of  some  diagnostic  significance  with 
regard  to  the  seat  of  the  lesion. 

2.  Vomiting.  Vomiting  is  almost  always  present.  At 
the  beginning  of  the  disease  ►^it  is  of  reflex  origin  due  to 
the  irritation  of  the  peritoneum ;  later  on  it  must  be  as- 
cribed principally  to  the  irregular,  strong,  i^eristaltic  con- 
tractions of  the  intestines.  The  api)earance  of  fecal  vom- 
iting was  believed  by  the  old  writers  to  be  a  sign  that  the 
obstruction  was  situated  in  the  large  bowel.  Nowadays, 
however,  it  is  generally  known  that  this  symptom  is  often 
present  in  cases  in  which  the  obstruction  is  situated  in  the 
ileum  or  even  in  the  jejunum.  The  reason  of  absence  of 
putrefactive  processes  in  the  intestinal  contents  normalh'  is 
the  rapidity  with  which  they  are  moved  farther  on  along 
the  canal  until  they  reach  the  large  bowel.  In  obstruction, 
however,  the  peristaltic  contractions  are  much  slower  and 
thus  putrefactive  processes  develop  even  in  the  small  bowel. 

In  order  to  explain  the  mechanism  of  stercoraceous  vom- 
iting a  reversed  peristaltic  or  antiperistaltic  motion  of  the 
intestines  was  formerly  assumed.  Of  late,  however,  the 
mechanism  of  fecal  vomiting  as  expounded  by  Haguenot ' 
as  early  as  1713,  is  now  generally  accepted.  According  to 
this  author,  stercoraceous  vomiting  takes  place  in  the  fol- 
lowing manner :  Above  the  occluded  intestine  there  is  an 
accumulation  of  more  or  less  liquid  intestinal  contents  in 

•  Haguenot :  "  Memoire  sur  les  Mouvernents  des  Intestins  dans  la 
Passion  Iliaque.  "  Histoire  de  1' Academic  Royale  des  Sciences,  Paris, 
1713. 

16 


242  DISEASES  OP  THE  INTESTINES. 

considerable  quantity;  the  bowels  being  distended  with 
large  amounts  of  gas  are  under  constant  pressure,  which 
is  increased  after  each  inspiration  and  especially  after 
energetic  contraction  of  the  abdominal  muscles,  occur- 
ring for  instance  during  the  act  of  vomiting.  Under  the 
influence  of  pressure  the  stagnant  liquid  contents  are  re- 
gurgitated from  above  the  occluded  spot  into  places  in 
which  there  is  less  resistance  and  thus  reach  the  duo- 
denum and  the  stomach.  Here  they  irritate  the  mucous 
membrane  and  cause  vomiting. 

This  theory  is  perfectly  in  accord  with  the  circumstance 
that  in  stercoraceous  vomiting  mostly  liquid  or  sometimes 
semi-liquid  contents  are  evacuated,  but  never  solid  fecal 
matter  j  for  even  in  obstruction  of  the  colon  the  fluid  will  be 
moved  farther  upward  while  solid  particles  will  remain  in 
the  lower  portion  of  the  bowel.  Vomiting  of  formed  fecal 
matter  is  a  very  rare  occurrence,  and  must  be  ascribed  to  an 
existing  fistulous  opening  between  the  colon  and  stomach. 

3.  Constipation.  Constipation  almost  always  exists  and 
is  very  obstinate.  After  injections,  very  rarely  spontane- 
ouslj^  there  may  be  a  slight  movement  of  the  bowel  con- 
sisting of  the  fecal  matter  lodged  below  the  occluded  spot. 
In  some  rare  instances  a  catarrhal  condition  may  exist 
in  the  segment  of  the  bowel  below  the  obstruction,  and 
the  patient  then  may  rather  have  diarrhoea  combined  with 
tenesmus.  Of  greater  significance  than  the  absence  of 
stools  is  the  inability  to  pass  wind  through  the  anus.  The 
passage  of  flatus  is  a  sure  sign  that  the  permeability  of  the 
intestine  has  been  re-established. 

4.  Meteorism.  Meteorism  is  the  result  of  increased  for- 
mation of  gas  developing  in  consetiuence  of  putrefactive 
processes  as  well  as  of  diminished  absorption.  According 
to  Zuntz,  the  absorption  of  intestinal  gases  into  the  blood 


ACUTE  OBSTRUCTION.  243 

takes  place  only  when  the  circulation  is  in  good  working 
order.  Meteorism  thus  indirectly  points  to  a  disturbed 
circulation  which  is  often  found  in  cases  of  incarcerations. 
If  meteorism  is  absent  the  absorption  of  gases  must  be 
assumed  to  take  place  as  rapidly  as  their  formation.  Me- 
teorism may  be  at  first  present  at  a  certain  circumscribed 
spot  of  the  abdomen  and  later  become  more  diffuse.  If 
the  place  at  which  it  first  appears  can  be  distinctly  defined, 
this  is  of  diagnostic  importance  with  regard  to  the  location 
of  the  occlusion. 

If  the  occlusion  is  in  the  large  bowel  the  portion  situated 
between  it  and  the  ileocaecal  valve  will  become  considera- 
bly distended  with  gas.  Thus  a  protrusion  of  the  right 
side  of  the  abdomen  will  be  noticed  when  the  obstruction 
is  at  the  right  flexure.  If  the  obstacle  is  situated  in  the 
rectum  there  is  at  first  a  protrusion  of  the  left  side  of  the 
abdomen  and  later  the  tympanites  will  involve  the  portion 
of  the  abdomen  situated  above  the  navel  (course  of  the 
transverse  colon) .  In  some  instances,  however,  obstruction 
of  the  rectum  may  be  acompanied  by  more  or  less  general 
meteorism.  This  is  especially  the  case  after  the  disease 
has  lasted  some  time ;  for  then,  as  a  rule,  the  resistance  of 
the  ileocaecal  valve  is  overcome  by  the  gas  pressure  and 
it  remains  more  or  less  patent  in  such  a  way  that  the  gases 
easily  penetrate  the  small  intestine. 

In  occlusions  affecting  the  duodenum  or  the  upper  part 
of  the  jejunum  the  meteorism  as  a  rule  involves  the  upper 
half  of  the  abdomen,  and  remains  confined  to  this  area. 
After  vomiting  there  is  usually  a  perceptible  decrease  of 
the  protrusion  for  a  short  while. 

If  the  meteorism  has  lasted  for  some  time  and  is  in- 
iense,  the  abdomen  assumes  a  barrel  shape.  This  is  espe- 
ciallv  found  in  cases  in  which  the  distended  intestinal  coils 


244  DISEASES  OF  THE  INTESTINES. 

are  already  paralyzed.  The  accumulatioD  of  gas  can  now 
go  on  without  encountering  much  resistance  and  thus  do 
great  harm.  The  diaphragm  is  then  pushed  upward.  The 
lungs  as  well  as  the  heart  become  compressed.  Stomach, 
liver,  and  bladder  are  compressed  by  the  intestinal  coils 
filled  with  gas  lying  upon  them.  In  a  similar  manner  the 
large  veins  (vena  cava,  vena  i^ortae,  etc.)  are  subjected  to 
the  same  disturbance.  Thus  the  function  of  many  impor- 
tant vital  organs  is  interfered  with  and  impaired  to  such  a  de- 
gree, if  this  condition  persists,  that  a  fatal  issue  may  occur. 

5.  Collapse.  The  diverse  symptoms  of  shock  which  ajv 
pear  in  a  marked  degree  in  cases  of  ileus  must  be  ascribed 
to  the  sudden  damage  inflicted  upon  the  peritoneum  and 
intestinal  wall  by  the  strangulating  agent.  The  mechani- 
cal irritation  involves  first  the  splanchnic  nerves,  and 
through  them  the  circulatory  apparatus.  As  a  conse- 
quence there  are  a  lowering  of  the  temperature  of  the  sur- 
face, cold  sweats,  lividit\'  of  the  extremities,  anaemia  of  the 
brain,  and  a  small  and  rai)id  pulse.  The  degree  of  the 
collapse  dejiends  upon  the  disposition  of  the  patient,  upon 
the  suddenness  of  the  strangulation,  and  upon  the  amount 
of  peritoneum  or  of  intestine  involved  in  the  lesion. 

The  gravest  amount  of  shock  is  met  with  in  cases  in  which 
a  considerable  segment  of  the  intestine  is  suddenly  strangu- 
lated and  an  injury  thus  abruptly  inflicted  upon  an  exten- 
sive nerve  area.  As  a  rule,  the  shock  met  with  in  cases  of 
obstruction  of  the  small  intestine  is  much  more  pronounced 
than  in  cases  in  which  the  obstruction  is  situated  in  the 
large  bowel.  The  reason  for  this  is  the  greater  supply  of 
nerves  and  the  greater  activity  of  the  small  intestine  as 
compared  with  the  large  bowel.  The  nerves  of  the  small 
intestine  are  also  more  directly  associated  with  the  great 
sympathetic  ganglia  of  the  abdomen. 


ACUTE  OBSTRUCTION.  245 

6.  The  Decrease  of  the  Amount  of  Fluid  in  the  Blood. 
In  intimate  connection  with  the  disturbance  of  the  nerves 
and  circulatory  functions  just  described  is  the  decrease  in 
the  amount  of  fluid  in  the  blood.  This  is  due  to  increased 
secretion  in  the  intestine  with  absence  of  absorption,  to 
vomiting,  and  to  increased  perspiration.  As  a  consequence 
tliere  exist  dryness  of  the  tongue  and  a  tormenting  thirst; 
the  urine  is  also  passed  only  in  small  quantities,  and  in 
some  instances  there  may  even  be  anuria. 

Certain  symptoms  which  occur  bat  rarely  and  also  be- 
long more  or  less  to  this  group  are  cramps,  tetanus,  coma, 
delirium,  fever.  Whether  these  symptoms  are  due  to 
auto-intoxication  or  to  other  factors  (especially  the  dry  con- 
dition of  the  blood)  is  as  yet  not  settled. 

ClJ^Ctice  /Signs. — inspection  reveals  eitner  z  symmetri- 
cal fulness  of  the  abdomen  (sometimes  barrel  shaped)  or  a 
l)rotrusion  of  certain  parts.  Thus,  as  mentioned  above, 
the  upper  part  of  the  abdomen  is  protruded  when  the  oc- 
clusion involves  the  duodenum  or  the  upper  part  of  the 
jejunum.  The  right  iliac  region  is  intensely  tympanitic 
if  the  occlusion  involves  the  hepatic  flexure,  while  the  left 
iliac  region  is  the  seat  of  the  protrusion  if  the  occlusion 
involves  some  portion  of  the  descending  colon.  After  the 
disease  has  existed  for  some  days  there  is  as  a  rule  a  gen- 
eral marked  swelling  of  the  abdomen. 

Palpation  reveals  in  some  cases  a  circumscribed  area 
which  is  painful  on  pressure  and  thus  serves  to  localize 
the  seat  of  the  disease.  This  is  especially  the  case  very 
soon  after  the  onset  of  the  symptoms.  In  the  larger  num- 
ber of  cases,  however,  there  is  a  special  tenderness  either 
in  the  region  of  the  navel  alone  or  over  the  entire  abdomen. 
In  comparatively  few  cases  will  i)alpation  reveal  a  tumor 
situated  deeply  within  the  abdomen  and  in  direct  connec- 


246  DISEASES  OP  THE  INTESTINES. 

tion  with  the  site  of  obstruction.  This  occurs  especially 
in  intussusception,  strangulation,  in  occlusions  due  to  com- 
pression by  tumors,  and  in  fecal  impaction.  After  a  thor- 
ough palpation  of  the  abdomen  a  digital  examination  of 
the  rectum  and  also  of  the  vagina  should  be  performed. 
It  is  hardly  necessary  to  add  that  a  thorough  examination 
should  be  made  of  any  existing  hernia  which  may  be  the 
seat  of  incarceration. 

By  means  of  auscultation  either  from  a  distance  or  in 
the  immediate  neighborhood  of  the  abdomen  we  are  often 
enabled  to  judge  about  the  state  of  the  intestinal  peristal- 
sis ;  for  when  the  latter  takes  place  in  a  \dolent  manner 
splashing  and  gurgling  noises  are  always  audible. 

Percussion  is  usually  of  great  importance.  In  general 
meteorism  it  permits  us  to  judge  of  the  position  of  the  dia- 
phragm and  liver.  If  j^ercussion  shows  a  change  in  char- 
acter over  a  certain  region  of  the  abdomen  during  a  period 
of  a  few  minutes,  it  follows  that  the  condition  of  an  intes- 
tinal coil  lying  beneath  has  undergone  some  change  in  its 
state  of  fulness,  and  thus  indicates  that  the  bowel  is  still 
in  active  peristalsis.  Auscultation  and  percussion  may  be 
used  conjointly  and  serve  the  same  purpose.  In  case  no 
change  whatever  is  noted  on  percussion  for  a  very  long 
period  of  time,  there  is  a  suspicion  that  paralysis  of  the 
bowels  exists.  The  liver  dulness  will  be  found  either 
partly  or  entirely  absent  in  almost  all  cases  of  perforation, 
but  in  Some  rare  instances  even  without  perforation.  lu 
the  latter  event  we  must  assume  that  intestinal  coils  filled 
with  gas  are  lying  above  the  liver.  I  have  observed  such 
a  case  with  recovery  during  the  last  year.  Sometimes  per- 
cussion may  help  to  discover  existing  exudation,  dulness 
being  found  in  the  lower  part  of  the  abdomen. 

Examination  of  the  vomited  matter  will  show  the  pres- 


ACUTE  OBSTRUCTION.  247 

ence  or  absence  of  fecal  elements.  The  urine  is  scanty, 
very  concentrated,  often  contains  albumin,  and  almost  al- 
ways shows  an  increase  of  indican  and  phenol.  Kosen- 
bach's  reaction  is  almost  always  present. 

Course. — The  course  of  an  acute  obstruction  will  depend 
first  upon  its  location,  and  secondly  upon  its  nature.  The 
higher  up  in  the  intestine  the  obstruction  is  situated  the 
more  rapid  as  a  rule  is  the  course  of  the  disease.  Volvu- 
lus and  strangulation  of  the  intestine  are  generally  accom- 
panied by  a  more  violent  course  than  is  obturation  by  for- 
eign bodies.  The  duration  of  the  disease  is  not  always 
the  same.  In  some  instances  the  patient  dies  very  soon, 
a  few  hours  or  a  day  or  two  after  the  commencement  of 
the  obstruction,  of  shock  and  paralysis  of  the  heart.  In 
other  instances  the  disease  lasts  several  days  or  even  a 
week.  In  intussusception  the  duration  of  the  disease  is 
longer,  several  weeks,  showing  periods  of  exacerbations 
and  remissions. 

If  the  patient  recovers  from  the  collapse  and  there 
is  a  spontaneous  re-establishment  of  the  patency  of  the  in- 
testinal lumen  (/.e.,  the  obstruction  is  relieved,  which  may 
happen  in  cases  of  invagination,  torsion,  and  obturation 
by  foreign  bodies),  there  is  at  first  as  a  rule  a  passage 
of  flatus,  which  may  be  followed  by  a  fecal  movement  of 
offensive  odor.  In  case  of  invagination  there  is  often  some 
blood  in  the  evacuation.  All  the  symptoms  which  have 
previously  existed  begin  to  abate,  the  fecal  vomiting  ceases, 
the  meteorism  becomes  less,  and  the  i:)atient  gradually  re- 
covers from  his  severe  illness.  In  cases  in  which  the  intes- 
tinal obstruction  has  led  to  considerable  anatomical  changes 
within  the  lumen  of  the  bowel  (ulcers,  gangrenous  proc- 
esses, adhesions),  after  a  period  of  comparative  euphoria, 
symptoms  of  chronic  intestinal  obstruction  may  develop. 


248  DISEASES  OF  THE  INTESTINES. 

In  the  greater  number  of  cases  of  acute  intestinal  ob- 
struction the  latter  persists,  and  the  patient,  if  not  oper- 
ated upon,  generally  dies  of  diffuse  peritonitis,  with  or 
without  perforation  of  the  intestines.  Even  without  per- 
foration, peritonitis  may  readily  develop  in  consequence  of 
the  paralytic  state  of  the  intestine ;  for,  according  to  Bon- 
necken, '  bacteria  can  easily  penetrate  the  intestinal  wall  as 
soon  as  the  latter  is  in  a  paralyzed  condition  and  thus  give 
rise  to  inflammation  of  the  peritoneum. 

Circumscribed  peritonitis  around  the  occluded  part  need 
not  give  distinct  symi)toms.  General  peritonitis,  however, 
always  enhances  the  alarming  symptoms  already  existing. 
Thus  the  meteorism  increases;  the  dyspncea,  hiccough, 
and  vomiting  become  more  violent,  the  ])ain8  unendur- 
able ;  the  heart  begins  to  give  out  and  pronounced  collai)8e 
appears.  Generally  there  is  a  rise  of  temperature  and 
frequently  a  fluid  exudation  within  the  abdomen  is  dis- 
coverable. If  perforation  of  the  intestine  has  taken  place, 
the  symptoms  just  described  appear  still  earlier  and  with 
more  violence.  The  abdomen  becomes  more  or  less 
rounded  and  the  diaphragm  is  pushed  upward  in  the  high- 
est degree.  The  liver  dulness  disappears  and  the  pains  be- 
come excruciating.  The  shock  may  be  so  great  that  the 
patient  becomes  unconscious  and  remains  so  until  death 
brings  relief. 

Complications  appearing  during  the  disease  may  also  be 
the  cause  of  death.  Thus  deglutition  pneumonia  (Schluck- 
pneumonie)  which  occasionally  occurs  by  aspiration  into 
the  lungs  of  gastric  and  intestinal  contents  during  the  act 
of  vomiting,  or  septicaemia  in  conse(]uence  of  intestinal  per- 
foration, may  develop  with  embolic  ])rocesses  in  the  lungs, 
liver,  and  other  organs.  In  exceptional  cases  there  occurs 
'  Bonnecken  :  Virchow's  Arcbiv,  Bd.  120. 


ACUTE  OBSTRUCTION.  249 

an  adhesion  of  the  occluded  intestinal  coils  to  the  anterior 
abdominal  wall,  and  after  the  gangrenous  destruction  of 
the  latter  as  well  as  of  parts  of  the  gut,  an  anus  praeter- 
naturalis develops,  or  a  fistulous  oi^ening  between  two  por- 
tions of  the  intestines,  or  again  a  fistula  of  the  intestine 
into  the  bladder,  uterus,  vagina,  or  stomach. 

Diagnosis. — The  diagnosis  must  deal  with  the  following 
three  i)oints :  A.  Recognition  of  the  intestinal  obstruction. 
B.  Its  seat.     C.  Iks  etiological  factor. 

A.  Recoijnition  of  the  Ldestinal  Obstruction.  The  recog- 
nition of  an  acute  intestinal  obstruction  is  not  difficult  if 
the  symptoiiis  described  above  are  present  in  a  marked 
degree.  Thus  total  absence  of  passage  of  fecal  matter  and 
flatus  combined  with  symptoms  of  collapse,  meteorism, 
pains,  and  fecal  vomiting  will  permit  a  positive  diagnosis 
of  intestinal  obstruction.  In  many  instances,  however,  only 
a  few  of  the  8ymi)toms  mentioned  are  present,  and  then 
the  diagnosis  is  quite  difficult.  The  symptom  of  the  great- 
est diagnostic  value  is  fecal  vomiting,  although  even  this 
alone  does  not  always  warrant  the  diagnosis  of  obstruction, 
for  it  also  occurs  in  intestinal  paralysis.  The  latter  con- 
dition must  be  especially  borne  in  mind  in  cases  in  which 
there  has  been  a  history  either  of  contusion  of  the  ab- 
domen or  of  a  reposition  of  incarcerated  hernia  shortly 
before  the  appearance  of  the  disease.  The  fecal  vomiting 
of  hysterics  can  also  be  easily  recognized,  as  there  are 
always  symptoms  present  which  indicate  the  true  condi- 
tion. 

The  greatest  difficulty  in  diagnosis  lies  in  the  differenti- 
ation between  intestinal  obstruction  and  diflfuse  peritonitis, 
especially  if  the  latter  accompanies  appendicitis.  AU  the 
symptoms  characteristic  of  intestinal  obstruction  may  oc- 
cur also  in  peritonitis.     A  thorough  consideration  of  all 


260  DISEASES  OP  THE  INTESTINES. 

the  symptoms  and  their  differentiation  in  these  two  dis- 
eases will,  however,  permit  a  decision. 

The  following  points  will  serve  as  a  guide  in  this  connec- 
tion :  In  acute  peritonitis  there  is  a  rise  of  temperature  at 
the  beginning  of  the  disease,  while  in  intestinal  obstruction 
there  is  at  first  no  fever  or  even  a  subnormal  temperature. 
There  are  exceptions,  however,  and  a  general  i^eritonitis  of 
a  grave  nature  may  run  its  course  without  anj'  fever  but 
with  symptoms  of  collapse.  The  pains  on  pressure  over  the 
abdomen  are  much  more  intense  in  peritonitis ;  in  intesti- 
nal occlusion  the  spontaneous  pain  may  occasionally  even 
be  relieved  by  pressure.  Fecal  vomiting  is  of  compara- 
tively rare  occurrence  in  peritonitis,  and  if  present  it  usu- 
ally appears  later  than  in  intestinal  obstruction.  The  me- 
teorism  is  diffuse  in  peritonitis  right  from  the  start.  It 
thus  causes  a  general  distention  of  the  abdominal  parietes. 
In/  obstruction  the  accumulation  of  gas  is  at  first  less  pro- 
nounced, circumscribed,  and  increases  gradually.  In  peri- 
tonitis the  abdomen  becomes  tense  from  the  first,  while  in 
obstruction,  at  the  commencement  at  least,  it  is  as  a  rule 
soft.  The  existence  of  an  exudation  speaks  in  favor  of 
general  peritonitis.  In  peritonitis  accompanying  appen- 
dicitis there  will  be  besides  the  above  symptoms  the  phe- 
nomena characteristic  of  the  latter  disease.  In  some  in- 
stances, however,  the  differentiation  between  peritonitis 
and  obstruction  will  hardly  be  possible  and  mistakes  are 
liable  to  occur. 

Acute  intestinal  obsti*uction  is  occasionally  simulated  by 
poisoning  with  arsenic  and  also  by  a  very  severe  attack  of 
cholera.  In  the  former  condition  there  will  be  a  history 
of  poisoning,  and  in  the  latter  the  presence  of  cholera  ba- 
cilli in  the  dejecta  will  clear  up  the  diagnosis.  In  rare 
instances  a  severe  attack  of  biliary  colic  or  of  renal  colic 


ACUTE  OBSTRUCTION.  251 

may  in  some  respects  resemble  intestinal  obstruction.  A 
thorough  examination,  however,  will  always  reveal  the  true 
condition.  In  biliary-  colic  as  a  rule  there  is  swelling  of 
the  liver  and  sometimes  jaundice;  in  reual  colic  the  pains 
radiate  from  the  kidney  to  the  bladder,  there  is  a  burning 
sensation  during  urination,  and  the  urine  often  contains 
mucus  and  occasionally  a  few  jjus  corpuscles  or  blood  cells. 
Intestinal  colic  resulting  from  chronic  lead  poisoning  occa-. 
sionally  simulates  true  obstruction  of  the  bowels.  The 
anamnesis,  however,  will  show  that  we  have  to  deal  with 
lead  poisoning.  Besides,  in  these  cases  there  is,  as  a  rule, 
a  more  or  less  sunken  condition  of  the  abdomen.  Simple 
intestinal  colic  (of  nervous  origin)  will  hardly  ever  give  idse 
to  mistakes  in  the  diagnosis,  as  the  clinical  picture  is  less 
severe  and  the  disease  quickly  subsides. 

B.  Location  of  the  Obstruction.  The  location  of  the  seat 
of  the  obstruction  is  not  merely  of  theoretical  value,  but  of 
great  practical  importance,  for  this  decides  the  question 
as  to  where  abdominal  incision  should  be  made  in  cases  of 
operation.  It  will  be  useful  to  discuss  first  at  what  point 
of  the  abdomen  the  obstruction  is  situated,  and  secondly, 
what  particular  portion  of  the  bowel  it  involves. 

1.  The  i3oiut  at  which  the  patient  first  experiences  pain 
is  significant  in  case  he  is  able  to  locate  it  definitely.  In 
many  instances,  however,  the  pain  is  not  experienced  in 
one  circumscribed  spot,  and  is  often  located  diflfusely  in 
the  neighborhood  of  the  navel.  The  presence  of  a  tensely 
tympanitic  intestinal  coil,  which  does  not  change  its  con- 
figuration and  thus  makes  the  abdominal  wall  protrude 
asymmetrically,  is  of  great  importance;  for,  according  to 
Von  Wahl,  such  a  coil  is  often  found  above  the  occluded 
segment  of  intestine.  Strong  peristaltic  contractions  run- 
ning in  the  same  direction  over  a  certain  region  of  the  ab- 


252  DISEASES  OF  THE  INTESTINES. 

domen,  especially  if  they  return  periodically  and  always 
in  the  same  area,  will  serve  to  locate  the  place  at  which 
the  obstruction  is  situated.  For  these  peristaltic  waves 
pass  along  the  intestine  down  to  the  seat  of  the  obstruc- 
tion, which  they  are  unable  to  overcome. 

Palpation  of  the  abdomen  occasionally  reveals  the  pres- 
ence of  a  sausage-like  tumor.  This  occurs  especially  in 
cases  of  intussusception.  If  such  a  tumor  is  present,  the 
location  of  the  obstiniction  is  certainly  easy.  A  thorough 
examination  of  all  hernial  openings  will  occasionallj'  re- 
veal an  incarceration  of  the  intestine  and  also  show  the 
site  of  the  lesion.  If  there  is  no  hernia  the  examination 
must  be  continued  through  the  vagina  and  through  the  rec- 
tum .  The  exploration  through  the  vagina  will  show  whether 
the  pelvic  organs  are  normal,  and  if  not,  whether  a  tumor 
orf:];:ie*i!!or  from  the  genital  organs  ^^  coxxipressing  the  in- 
testines. Digital  examination  of  the  rectum  will  enable  us 
to  discover  a  stricture,  an  intussusception,  or  a  tumor  of 
the  lower  portion  of  the  bowel.  In  some  cases  a  thorough 
examination  of  the  entire  rectum  and  the  descending  colon 
may  be  undertaken  with  the  whole  hand  under  chloroform 
narcosis,  according  to  the  method  of  Simon.  In  cases  of 
intussusception  involving  the  sigmoid  flexure  and  rectum, 
the  anus  often  remains  open  (paralysis  of  the  sphincters) 
and  there  appears  an  involuntary  evacuation  of  a  muco- 
bloody  fluid  from  time  to  time. 

2.  Determination  of  the  Portion  of  the  Intestinal  Tract  in 
which  the  Ohstruction  is  Situated.  Small  Intestine.  If  the 
obstruction  is  situated  in  the  small  intestine  aU  the  symp- 
toms (pains,  vomiting,  collapse)  are,  as  a  rule,  much  more 
intense  and  appear  sooner  than  in  obstruction  of  the  large 
bowel.  Soon  after  the  commencement  of  the  disease,  tliere 
is  copious  vomiting  which  may  become  fecal  after  a  short 


ACUTE  OBSTRUCTION.  263 

period.  The  meteorism  at  the  beginning  is  localized  in  the 
upper  part  of  the  abdomen,  while  the  lower  part  remains 
unchanged.  Pronounced  visible  peristaltic  waves  in  the 
small  intestine  also  point  to  an  occlusion  situated  within 
the  latter. 

Jaffe  '  was  the  first  to  show  that  obstruction  of  the  small 
intestine  gives  rise  to  pronounced  iudicanuria.  As  early 
as  the  second  or  third  day  of  the  obstruction,  indicau  can 
be  found  in  the  urine  in  large  quantities.  In  obstruction 
of  the  large  bowel  there  is  as  a  rule  no  indicanuria,  and  if 
it  appears  it  does  so  only  later  in  the  disease,  on  the  sixth 
or  seventh  day.  The  higher  up  in  the  intestinal  tract  the 
obstruction  is  situated,  the  sooner  and  the  more  frequently 
anuria  may  appear.  Injections  of  water  into  the  bowel 
may  secure  a  fecal  evacuation.  The  colon  can  also  be 
filled  with  a  large  amount  of  water  or  gas. 

If  the  obstruction  is  situated  within  the  duodenum  or  in 
the  upper  part  of  the  jejunum,  it  can  often  be  easily  recog- 
nized. Obstruction  of  the  duodenum  above  Vater's  papilla 
will  manifest  the  same  symptoms  as  acute  dilatation  of  the 
stomach  in  consequence  of  a  stricture.  There  will  be  ischo- 
chymia  and  continuous  vomiting  of  chyme.  An  obstruc- 
tion situated  within  the  duodenum  below  Vater's  papilla 
will  give  rise  to  vomiting  of  large  quantities  of  pure  bile. 
The  vomited  matter  may  contain  acids  from  admixture  of 
gastric  juice.  It  is  ^ever  fecal  in  character.  The  gastric 
region  is  protuberant  but  sinks  in  after  a  spell  of  vomiting. 

If  the  obstruction  is  situated  within  the  beginning  of  the 
jejunum  the  vomiting  assumes  at  first  a  greenish  hue  (de- 
composed bile)  which  may  be  followed  by  the  vomiting  of 
pure  unchanged  yellow  bile.  Occasionally  the  vomited 
matter  assumes  a  fecal  character.  01)structions  situated 
'  Jaffe  :  Centralbl.  f.  die  med.  Wissenschaften,  1872. 


264  DISEASES  OF  THE  INTESTINES. 

within  the  duodenum  or  at  the  beginning  of  the  jejunum, 
as  a  rule,  are  unaccompanied  with  indicanuria. 

Obsti-uction  of  the  Large  Bowel.  The  symptoms  here 
are  usually  less  violent  and  appear  a  little  later  than  in 
the  obstruction  of  the  small  intestine.  Fecal  vomiting 
often  appears  long  after  the  establishment  of  the  occlusion, 
and  it  may  even  be  absent  if  the  obstacle  is  situated  at  the 
beginning  of  the  descending  colon  or  lower  down.  The 
meteorism  is  in  most  instances  limited  to  the  lower  parts 
of  the  abdomen  and  also  to  the  lumbar  regions.  In  occlu- 
sion of  the  descending  colon  it  may  be  noticeable  that  at 
first  there  is  a  protrusion  in  the  left  iliac  region,  afterward 
a  protrusion  of  the  transverse  colon,  and  ultimately  the  as- 
cending colon  will  also  become  tympanitic.  As  mentioned 
above,  indicanuria  will  be  absent  during  the  first  five  or  six 
days  of  illness. 

With  regard  to  the  determination  of  the  occlusion  within 
the  lower  parts  of  the  colon,  Brinton's  '  method^  already  in 
use  over  fifty  years  ago,  is  verj-  valuable.  It  consists  in 
filling  up  the  bowel  with  water  through  the  rectum.  If 
not  more  than  half  a  quart  can  be  injected,  the  obstruction 
must  be  situated  in  the  upper  part  of  the  rectum.  If  one 
to  two  quai^ts  can  be  injected,  the  obstruction  must  be  situ- 
ated above  the  sigmoid  flexure,  in  the  descending  colon, 
or  still  higher.  In  case  obstruction  is  situated  in  the  as- 
cending colon  four  quarts  or  still  more  can  be  injected  and 
retained  in  the  bowel.  Insufflation  of  air  or  carbonic  acid 
gas  into  the  rectum  will  also  occasionally  show  the  seat  of 
the  obstruction,  if  the  latter  is  situated  in  the  descending 
or  the  transverse  colon,  as  there  will  be  a  filling  up  with 
gas  of  the  free  portion  of  the  bowel  up  to  the  obstructed 
point.  When  the  obstruction  is  located  beyond  the  trans- 
'  Brinton  :  "On  Intestinal  Obstruction,  "  London,  1867. 


ACUTE  OBSTRUCTION.  265 

verse  colon,  however,  it  will  not  permit  of  distinct  recog- 
nition by  this  method. 

C.  Recognition  of  the  Different  Fwrns  of  Acute  Obstruction. 
If  the  diagnosis  of  acute  obstruction  of  the  bowels  is  not 
always  easy,  the  recognition  of  the  special  anatomical 
lesion  underlying  it  is  still  more  difficult.  In  many  in- 
stances an  exact  anatomical  diagnosis  will  not  be  possible 
and  we  will  have  to  be  satisfied  with  a  probable  conjecture. 
In  some  cases,  however,  the  exact  determination  of  the 
etiological  factor  underlying  the  obstruction  will  be  possi- 
ble. The  following  groups  of  acute  obstruction  of  the 
bowels  can  be  clinically  differentiated : 

1.  Acute  Incarceration  of  the  bowels  in  hernias  (also  in- 
ternal hernias,  in  slits  of  the  omentum,  mesentery,  or  di- 
verticula), in  strangulation  by  bands  or  twists  of  the  bowel, 
is  most  frequent  between  the  ages  of  twentj'  and  forty. 
It  occurs  more  often  in  males  than  in  females.  There  is 
often  a  previous  history  of  peritonitis,  of  hernia,  or  of  acci- 
dents (contusions).  The  onset  of  the  disease  is  sudden. 
The  pains  are  severe.  Vomiting  is  present  from  the  start, 
becoming  stercoraceous  later  on.  Collapse  is  marked. 
Tenesmus  is  absent.  Physical  examination  of  the  abdo- 
men gives,  as  a  rule,  negative  results. 

2.  Volvulus  most  often  involves  the  sigmoid  flexure  and 
can  then  be  easily  recognized.  Volvulus  of  the  small  in- 
testine, which  occurs  very  rarely,  cannot  be  differentiated 
clinically  from  incarceration.  The  rotation  of  the  bowel 
around  its  axis  is  either  complete  (360°)  or  incomplete 
(half  rotation,  180°).  In  the  first  instance  there  is  total 
occlusion,  while  in  the  latter  the  intestinal  lumen  is  at  first 
partially  pervious.  Volvulus  is  more  common  in  males 
than  in  females  in  the  i>roportion  of  four  to  one,  and  occurs 
principally  late  in  life,  usually  between  forty  and  sixty. 


266  DISEASES  OP  THE  INTESTINES. 

There  is  usually  an  antecedent  history  of  chronic  constipa- 
tion. The  onset  of  the  disease  is  sudden.  The  pain  ordi- 
narily is  intermittent.  Vomiting  may  be  absent  at  first  and 
later  on  occurs  intermittently.  Constipation  is  almost  ab- 
solute and  grows  worse  after  the  use  of  aperients.  There 
is  pronounced  meteorism.  The  sigmoid  flexure  can  oc- 
casionally be  felt  as  a  tumor.  Only  moderate  amounts  of 
water  can  be  injected  into  the  rectum. 

3.  Intussusception  occurs  very  frequently  in  early  child- 
hood. The  onset  is  sudden,  the  pains  appear  early,  are 
colicky  in  character  and  come  in  paroxysms.  There  are 
marked  tenesmus  and  blood}'  evacuations.  The  collapse 
is  not  pronounced.  The  invaginated  coil  may  be  acces- 
sible to  palpation  and  then  appears  in  the  form  of  a  tumor 
of  egg-size  or  somewhat  larger,  this  occurring  in  about 
fifty  per  cent  of  the  cases.  Meteorism  develops  in  con- 
junction with  peritonitis. 

4.  Obturation  of  the  Intestine  by  Gall  Stones,  Enteroliths, 
or  Foreign  Bodies.  Obstruction  by  gall  stones  occurs  chiefly 
in  women  and  is  more  frequent  at  an  advanced  age.  A  pre- 
vious history  of  gall  stones  or  a  preceding  attack  of  jaun- 
dice, pains  in  the  region  of  the  liver,  and  swelling  of  this 
organ  are  points  which  aid  in  the  diagnosis.  Obstruction 
by  gall  stones  usually  occurs  in  the  small  intestine;  the 
symptoms,  as  a  rule,  are  less  severe  than  in  other  forms 
of  ileus.  The  collapse  is  not  pronounced  or  may  be  en- 
tirely absent.  Flatus  may  occasionally  be  passed,  copious 
vomiting  of  bile  may  be  present.  If  the  gall  stone  is  situ- 
ated in  the  lower  portion  of  the  ileum  the  vomiting  may 
later  become  stercoraceous.  Occasionally  the  stones  can 
be  palpated  through  the  abdomen  and  felt  as  a  hard  mass. 
Meteorism  is  generally  not  highly  developed.  In  some 
instances  there  is  diarrhoea  with  admixture  of  blood,  the 


ACUTE  OBSTRUCTION.  257 

latter  being  due  to  abrasions  of  the  intestinal  mucosa  pro- 
duced by  friction  of  rough  gall  stones. 

The  recognition  of  an  enterolith  as  the  cause  of  obstruc- 
tion is  very  difficult  and  possible  only  when  small  frag- 
ments of  a  fecal  calculus  have  previously  been  found  in  the 
dejecta.  The  seat  of  obstruction  is  as  a  rule  then  in  the 
large  bowel,  the  latter  being  the  place  where  enteroliths 
develop. 

Obstruction  by  foreign  bodies  will  be  recognized  by  the 
previous  history;  often  also,  especially  if  they  are  of  a 
metallic  nature,  by  a  Roentgen  picture.  An  accumulation 
of  cherry  pits  or  plum  stones  may  also  cause  an  obstruc- 
tion and  will  likewise  be  recognized  by  the  previous 
history  and  by  the  presence  of  some  of  them  in  the  de- 
jecta. 

Hardened  fecal  matter  will  very  rarely  give  the  picture 
of  obstruction.  This  will  occur  only  in  very  weakened  in- 
dividuals and  in  persons  with  spinal  trouble.  In  these 
cases  the  rectum  and  colon  will  be  found  filled  with  greatly 
hardened  scybala.  If  a  stricture  or  a  tumor  exists  within 
the  intestine  and  narrows  its  lumen,  an  accumulation  of 
fecal  matter  above  the  stricture  gives  rise  to  acute  ob- 
struction. 

5.  Dynamic  Ileus.  Obstruction  due  to  paralysis  of  a 
segment  of  the  bowel  can  be  recognized  only  with  great 
difficulty.  Often  there  has  been  a  preceding  laparotomy 
or  some  operation  on  the  genital  organs  in  the  female  or 
a  history  of  a  replaced  hernia. 

With  regard  to  the  recognition  of  the  different  forms  of 

intestinal  obstruction  the  following  table,  which  gives  the 

frequency  of  the  principal  symptoms  in  the  various  forms 

of  obstruction,  may  be  of  assistance. 

Among  two  hundred  and  ninety -five  cases  of  acute  ob- 
17 


258 


DISEASES  OF  THE  INTESTINES. 


struction  of  the  bowels  collected  in  literature  and  minutely 
examined  by  K.  Fitz '  of  Boston,  the  symptoms  were  as 
follows  with  regard  to  the  different  groups  of  obstruction : 


Pain 

Nausea  and  vomiting 

Fecal  vomiting 

Tympanites 

Tumor 

Visible  coils 


Strangu- 

Intui^sus- 

Gall 

latiou. 

ception. 

Twist. 

stones. 

Per  Cent. 

Per  Cent. 

Per  Cent. 

Per  Cent. 

82 

70 

60 

83 

69 

75 

37 

74 

47 

13 

15 

61 

56 

33 

65 

56 

10 

69 

13 

11 

7 

Stricture 
or  Tumor. 
Per  Cent. 


60 
80 
33 
66 
27 
20 


Prognosis. — The  prognosis  of  acute  obstruction  of  the 
bowel  is  very  serious.  According  to  Curschmann/  only 
thirty  to  thirty-five  patients  out  of  one  hundred  recover 
from  this  disease.  As  a  rule  ileus  caused  by  coprostasis 
or  by  obturation  with  gall  stones  and  foreign  bodies  gives 
the  best  prognosis.  Then  come  volvulus  and  intussuscep- 
tion, while  incarceration  gives  the  worst  prognosis.  If  in 
the  course  of  ileus  deglutition  pneumonia  or  diffuse  peri- 
tonitis or  perforation  of  the  bowel  develops,  then  the  case 
is  well-nigh  hopeless.  Operative  intervention,  especially 
in  cases  in  which  the  seat  of  the  intestinal  occlusion  is 
known,  improves  the  prognosis  considerably,  but  only  if 
it  is  resorted  to  early.  Later,  when  the  complications  just 
mentioned  arise,  not  much  can  be  expected  from  an  opera- 
tion. 

Treatment 

A.  Medical  Treatment. — Absolute  rest  is  of  the  great- 
est importance.  The  patient  should  be  kept  in  bed  and 
told  to  avoid  any  abrupt  motions.      He  should  not  be 

'  R.  Fitz:  "Transactions  of  the  Congress  of  Physicians  and  Sur- 
geons," vol.  i..  1888. 

*  Curschmann  :  "  Die  Behandlung  des  Ileus.  "  Congress  filr  innere 
Medicin,  Wiesbaden,  1889. 


ACUTE  OBSTRUCTION.  269 

allowed  to  go  to  the  water-closet,  but  should  use  a  bed- 
pan. With  Treves,  Graser, '  and  others  I  am  for  absolute 
rest  of  the  stomach  and  intestines,  i.e.,  no  food  whatever 
should  be  given  to  patients  suffering  from  acute  obstruc- 
tion of  the  bowels. 

If  there  is  great  thirst  a  teaspoonful  of  hot  water  or  very 
weak  tea  may  be  given  every  half-hour  or  hour  or  a  small 
piece  of  ice  may  be  held  in  the  mouth  until  it  melts,  but 
the  water  should  not  be  swallowed.  Neither  should  any 
stimulants  like  wine,  champagne,  or  whiskey  be  given  by 
the  mouth.  In  obstruction  of  the  small  intestine  small 
quantities  of  a  saline  solution  (about  seven  to  twelve  ounces) 
may  be  injected  into  the  bowel  several  times  during  the 
day.  If  the  sickness  lasts  several  days,  nutritive  enemas 
consisting  of  milk  and  egg  or  of  a  peptone  solution  may 
be  given  in  the  same  way.  If,  however,  the  patient  is  not 
able  to  retain  the  enema,  considerable  quantities  of  saline 
solution  must  be  injected  either  subcutaneously  or  intra- 
venously. 

All  writers  agree  that  no  cathartic  remedies  whatever 
should  be  used,  as  they  increase  the  peristalsis  and  there- 
by may  cause  great  harm.  A  cathartic  should  be  per- 
mitted only  in  cases  in  which  the  obstruction  is  positively 
due  either  to  gall  stpnes  or  hardened  fecal  masses  or  in 
dynamic  ileus.  It  is,  however,  of  benefit  to  evacuate  the 
lower  parts  of  the  bowel  by  means  of  an  enema.  This 
cleans  out  the  rectum,  diminishes  the- feeling  of  tension  to 
a  slight  extent,  and  prepares  the  bowel  for  the  nutrient  * 
enemas. 

The  administration  of  (ypium  plays  a  principal  part.     It 

'Graser:  "Behandlung  der  Darmverengerung  und  des  Darmver- 
schlusses."  Penzoldt  Stintzing's  "Handbuch  der  speciellen  Therapie 
innerer  Kraukheiten,  "  Jena,  1896. 


260  DISEASES  OF  THE  INTESTINES. 

is  indicated  not  only  as  a  means  of  allaying  pain  but  for 
its  soothing  action  upon  the  intestinal  peristalsis.  The 
arrest  of  the  latter  may  have  a  direct  curative  effect,  since 
it  may  promote  a  return  of  the  partly  incarcerated  or  in- 
vaginated  or  slightly  twisted  coil  to  its  normal  position. 

In  order  to  secure  a  prompt  action  of  the  drug  it  is  best 
to  first  give  a  hypodermic  injection  of  morphine,  one-sixth 
to  one-fourth  of  a  grain.  A  short  time  afterward  a  sup- 
pository of  two-thirds  of  a  grain  of  opium  is  administered 
and  repeated  every  three  or  four  hours  until  the  pains  are 
kept  in  abeyance.  In  cases  in  which  the  vomiting  is  not 
so  marked,  opium  may  be  given  in  the  form  of  the  tincture 
fifteen  to  twenty  drops  every  tliree  to  four  hours.  It  is 
hardly  necessary  to  say  that  the  opiates  should  not  be  used 
too  lavishly.  Only  so  much  should  be  administered  as  is 
absolutely  necessary  for  relieving  the  pain  and  quieting 
the  violent  peristalsis  of  the  intestine.  Given  in  this  way, 
opium  not  only  acts  as  a  sedative  but  also  as  a  stimulant 
on  the  heart.  Patients  in  deep  collapse  very  soon  after  an 
injection  of  morphine  become  warm,  show  a  better  pulse 
and  a  more  normal  temperature.  The  only  disadvantage 
of  opium  is  that  it  slightly  masks  the  true  picture  of  the 
disease.  It  is  therefore  best  whenever  possible  first  to 
make  an  exact  diagnosis  by  thorough  examination  of  the 
abdominal  viscera  by  palpation,  auscultation,  etc.,  before 
administering  it. 

If  the  symptoms-  of  the  disease  persist  after  the  admin- 
istration of  opium,  especially  if  the  tension  of  the  abdomen 
is  not  relieved  and  no  flatus  is  passed,  it  is  well  to  dis- 
continue the  remedy  for  a  certain  period  of  time.  This 
will  enable  the  physician  to  judge  the  situation  critically. 

As  a  further  sedative  agent  applications  of  poultices  can 
be  considered.     A  hot-water  bag,  a  hot  plate  wrapped  up 


ACUTE  OBSTRUCTION.  261 

in  flannel,  or  a  Japanese  warm  box,  wet  packs  (Priessnitz) 
are  useful.  If  there  are  signs  of  peritoneal  inflammation, 
applications  of  ice  or  of  very  cold  poultices  are  prefer- 
able. 

Lavage  of  the  stomach  was  first  recommended  in  this 
disease  by  Kussmaul  and  Cahn.'  This  procedure  is  of 
benefit  if  the  obstruction  is  situated  high  up  in  the  small 
intestine.  It  empties  the  stomach,  relieves  the  vomiting, 
and  also  decreases  the  abdominal  tension.  There  is  no 
doubt  that  this  therapeutic  measure  is  sometimes  crowned 
with  success  in  appropriate  cases.  As  a  striking  instance 
of  the  efficacy  of  this  mode  of  treatment  the  following  case 
may  be  reported : 

E.  K.,  thirty -five  years  old,  had  always  been  well,  when 
he  suddenly  became  critically  ill  with  violent  abdominal 
I^ains  and  constant  vomiting.  For  three  days  there  was 
no  evacuation  of  the  bowels  nor  was  the  patient  able  to 
pass  any  flatus.  On  examination  I  found  his  abdomen 
considerably  distended  and  tense.  The  stomach  could  be 
mapped  out  and  was  considerably  dilated,  the  greater  cur- 
vature extending  a  hand's  width  below  the  navel.  On  pal- 
pation there  was  considerable  tenderness  all  over  the 
abdomen.  The  pulse  was  quite  frequent  (110)  and  weak, 
temperature  96.5°  in  the  mouth,  the  extremities  were  cold. 
The  face  showed  an  expression  of  great  suffering.  There 
were  almost  continuous  hiccough  and  now  and  then  vomit- 
ing of  a  watery,  turbid,  somewhat  brownish-looking  liijuid 
with  fecal  odor.  On  introducing  the  tube  over  a  quart  of 
liquid  of  the  same  character  was  obtained.  The  stomach 
was  then  washed  out  with  several  quarts  of  water  uutil  the 
fluid  returned  cpiite  clear.  The  patient  felt  somewhat  re- 
lieved. The  vomiting  stopped  and  on  the  followiug  day 
there  was  a  s])ontaueous  evacuation  of  the  bowels.  The 
patient  was  now  able  to  pass  flatus,  the  distention  sub- 

'  Kussmaul -Calm  :  "Heilung  von  Ileus  durch  Magenausspulung. " 
Berl.  klin.  Wocbeuschr.,  1884.  Nos.  43  and  43. 


262  DISEASES  OF  THE  INTESTINES. 

sided,  and  he  gradually  recuperated.  For  the  sake  of  com- 
pleteness I  would  add  that  besides  washing  out  the  stomach, 
the  treatment  consisted  in  the  administration  of  opium 
suppositories. 

Lavage  of  the  Bowel.  Injections  of  large  amounts  of 
water  into  the  bowel  under  considerable  pressure  are  also 
occasionally  of  benefit,  especially  in  cases  of  intussuscep- 
tion of  the  colon  or  when  a  foreign  body  or  hardened  fecal 
matter  is  the  cause  of  the  obstruction  within  the  large 
bowel.  According  to  Treves,  it  is  desirable  to  use  this 
procedure  after  anaesthetizing  the  patient.  A  considerable 
quantity  of  water  (varying  according  to  the  age  of  the  pa- 
tient from  half  a  pint  to  three  quarts)  is  introduced  into 
the  bowel  by  means  of  an  ordinary  fountain  syringe.  The 
fluid  is  allowed  to  remain  in  the  colon  for  at  least  ten  min- 
utes. While  injecting  the  water  it  is  best  to  have  the  pa- 
tient in  such  a  position  that  his  head  is  lowered  and  his 
pelvis  is  raised.  While  the  irrigation  of  the  bowels  is 
going  on  the  physician  should  hold  his  hand  upon  the 
patient's  abdomen  and  in  this  way  notice  any  change  which 
may  occur. 

In  intussusception  when  the  tumor  can  be  felt  the 
latter  will  in  some  instances  suddenly  disappear,  giving 
way  to  the  pressure  of  the  water.  Too  great  force, 
however,  should  never  be  used,  as  this  may  bring  on  rup- 
ture of  the  bowels.  Instead  of  water,  injections  of  warm 
olive  oil,  which  were  first  recommended  by  Kussmaul  and 
Fleiner,  may  be  used  in  the  same  way.  Dr.  Klubbe '  has 
related  three  cases  of  cure  by  means  of  this  method. 

Inflation  of  the  Boivel  ivith  Air  or  Certain  Gases  in 
Cases  of  Invagination.     Trastour  ^  recommended  inflation 

'  Klubbe  ;  British  Medical  Journal,  November  6th,  1897. 
"  Trastour  :  Bulletin  General  de  Therapie,  1874,  p.  107. 


ACUTE  OBSTRUCTION.  263 

of  the  bowel  with  air  by  means  of  a  common  bellows,  to 
which  aD  India-rubber  nozzle  and  rectal  tube  had  been 
attached.  The  forcible  filling  up  of  the  bowel  with  air  is 
capable  of  producing  the  same  effect  as  the  injection  of 
water  and  may  free  the  invaginated  portion.  Von  Ziems- 
sen  '  has  recommended  the  use  of  carbonic-acid  gas,  while 
Senn "  suggested  hydrogen  gas.  Carbonic-acid  gas  is  best 
used  in  the  form  of  "sparklets,"  as  suggested  by  Dr.  A. 
Rose '  of  New  York.  Care  must  be  taken  not  to  fill  up  the 
bowel  too  quickly  and  too  forcibly. 

Massage.  Massage  has  been  recommended  by  several 
writers.  Its  use,  however,  is  not  entirely  harmless.  It 
can  be  of  benefit  only  in  cases  of  obstruction  by  gall  stones 
and  fecal  matter,  but  even  in  these  cases  extreme  care  in 
its  use  is  necessary. 

Electricity.  Electricity  has  especially  been  recom- 
mended by  Boudet.  Among  seventy  cases  of  ileus  Boudet  * 
had  fifty -three  recoveries  by  this  method.  The  faradic  or 
galvanic  current  may  be  used.  In  the  application  of  the 
faradic  current  one  metal  electrode  of  cone  shape  is  in- 
sei-ted  into  the  rectum  while  another  large  plate  electrode 
is  kept  over  the  abdomen  for  about  ten  to  twenty  minutes. 
In  using  the  galvanic  current  it  is  necessary  to  have  a 
special  rectal  electrode,  which  is  constructed  in  such  a  way 
that  water  running  through  it  forms  the  conductor,  so  as 
to  avoid  burning  the  mucosa.  The  other  electrode  is  placed 
over  the  abdomen.  The  negative  pole  should  be  inside. 
The  strength  of  the  current  should  vary  from  ten  to  fifteen 
milliamperes.  The  duration  of  the  treatment  should  be 
twenty  to  twenty-five  minutes. 

'  Von  Ziemssen  .  Archiv  fiir  klinische  Medizin.  Bd.  33.  Heft  8  and  4. 

» Nic.  Senn :  "  Intestinal  Surgery,  "  Chicago,  1889,  p.  244. 

'  A.  Rose  :  New  York  Med.  Journal,  1900,  i.,  p.  47. 

♦  Boudet ;  Progres  Medical,  February  7th  and  14th.  1885. 


264  DISEASES  OF  THE  INTESTI^^Li. 

Electricity  will  be  of  special  value  in  obstruction  due 
to  hardened  fecal  matter  or  in  the  paralytic  form  of  ileus, 
while  in  incarceration  it  is  rather  contraindicated. 

Puncture.  Puncture  of  the  distended  bowel  has  recently 
been  recommended  anew  by  Curschmann,'  von  Ziemssen, 
and  others.  According  to  Curschmann,  puncture  of  the 
intestine  is  performed  in  the  following  way :  A  long  aspi- 
rator needle  of  thin  calibre  (like  that  of  a  Pravaz  syringe) 
provided  with  a  stopcock  is  thrust  into  the  abdomen  over 
a  prominent  coil  of  the  intestine.  A  piece  of  rubber  tub- 
ing is  then  connected  with  the  outer  end  of  the  needle; 
the  free  end  of  the  latter  is  inserted  into  a  bottle  filled  with 
water,  which  is  turned  upside  down  in  a  basin  likewise 
filled  with  water".  The  stopcock  of  the  aspirating  needle 
is  now  opened  and  the  gas  escaping  from  the  intestinal 
coil  appears  in  bubbles  rising  to  the  upper  part  of  the 
bottle,  displacing  the  water.  There  is  no  doubt  that  con- 
siderable temporary  relief  can  be  afforded  by  this  mode  of 
procedure,  as  it  lessens  the  feeling  of  tension.  Occasion- 
ally it  may  also  have  a  direct  curative  result.  Thus 
Curschmann  reports  three  cures  by  this  method.  Punc- 
ture, however,  is  not  entirely  free  from  danger.  In  cases 
in  which  the  intestine  is  already  partly  paralyzed,  the 
opening  after  the  withdrawal  of  the  needle  may  not  entirely 
close  and  intestinal  gases  and  contents  may  continue  to 
ooze  out  and  cause  peritonitis. 

Most  surgeons  of  note  are  against  this  i)rocedure,  as  it 

lacks  precision  and  is  not  free  from  danger.     Thus  Treves,* 

Kocher,"  and  Graser^  are  all  opposed  to  its  employment. 

'  Curschmann    Deutsche  med.  Wochenschrift,  1887,  No.  21. 
» Treves:  "Intestinal  Obstruction,  "  New  York,  1899.;).  471. 
^Kocher:    "Mittheilungen  aus  den  Grenzgebieten   der  Medizin," 
1898.  Bd.  4,  p.  2. 
*  Graser ;  Penzoldt-Stinzing's  "  Handbuch,  "  Bd.  4,  p.  563. 


ACUTE  OBSTRUCTION.  265 

Sad  experiences  with  puncture  have  been  reported  by 
Frentzel,'  Fiirbringer/  Hoffmann,  Korte,"  and  Graser. 
The  latter  observed  the  appearance  of  fecal  matter  and 
consecutive  peritonitis  from  such  an  opening.  He  con- 
siders puncture  permissible  only  if  the  patient  absolutely 
refuses  an  operation, 

3Iercunj  Qlercurius  Vivus).  The  internal  administration 
of  pure  mercury  in  tablespoonful  doses  was  highly  es- 
teemed as  a  remedy  for  ileus  by  the  old  physicians.  When 
all  resources  had  been  exhausted  without  success,  mercury 
was  given  as  an  ultimum  refugium.  Even  nowadays  many 
physicians  are  convinced  of  its  efficacy.  The  use  of  mer- 
cury in  incarceration,  strangulation  of  the  bowel  by  twists 
or  bands,  intussusception,  is  not  permissible,  as  it  does 
real  harm.  In  ileus  in  consequence  of  coprostasis  or  in 
dynamic  ileus,  mercury  may  be  employed  if  all  other  rem- 
edies have  proven  futile.  Its  effect  consists  in  the  pene- 
tration of  the  mercury  into  the  accumulated  fecal  matter, 
thus  softening  it. 

All  the  enumerated  internal  methods  of  treatment  must 
be  applied,  first,  in  cases  in  which  the  obstruction  is  due 
either  to  gall  stones  or  to  foreign  bodies  or  fecal  accumu- 
lation or  volvulus  of  the  sigmoid  flexure ;  secondly,  in  cases 
in  which  the  exact  diagnosis  as  to  the  kind  of  obstruction 
is  not  settled,  and  which  are  not  of  a  very  severe  type.  In 
all  other  varieties  of  intestinal  obstruction  and  even  in  the 
types  just  mentioned,  after  the  failure  of  the  medicinal 
measures  at  hand,  an  operation  should  be  resorted  to. 

'  Frentzel :  Deutsche  Zeitschr.  f.  Chirurgie,  Bd.  83. 

'  Ftirbringer  :  Verhandl.  des  8ten  Congresses  f.  ianere  Medicin,  1889. 

■'  K5rte :  Ibidem. 


266  DISEASES  OP  THE  INTESTINES. 

B.  Surgical  Treaiment. 

Treves,  the  greatest  authority  on  intestinal  obstruction, 
says:  "There  is  one  measure  for  the  treatment  of  acute 
intestinal  obstruction,  and  that  is  by  means  of  laparotomy. 
The  operation  should  be  performed  at  the  earliest  possible 
moment,  as  soon  indeed  as  the  diagnosis  is  reasonably 
clear.  In  case  of  acute  abdominal  trouble  in  which  the 
diagnosis  is  not  clear,  the  better  and  safer  course  is  to 
operate. "  This  view  is  now  generally  accepted  by  physi- 
cians as  well  as  surgeons. 

As  mentioned  above,  obturation,  ileus,  and  volvulus  of 
the  sigmoid  flexure  are  the  only  groups  of  intestinal  ob- 
struction in  which  medical  treatment  plays  a  prominent 
part.  The  importance  of  an  early  operation  has  been 
shown  by  Naunyn,  who  found  that  among  two  hundred 
and  eighty -eight  cases  of  ileus  operated  upon,  the  results 
were  the  more  favorable  the  earlier  recourse  was  had 
to  surgical  intervention.  In  those  cases  in  which  the 
operation  was  xjerformed  during  the  first  two  days  of 
sickness  recovery  took  place  in  seventy-five  per  cent. 
During  the  third  day  and  still  later  there  were  only 
thirty -five  to  forty  per  cent  of  recoveries. 

A  similar  view  is  expressed  by  Gibson, '  who  dealt  par- 
ticularly with  acute  intussusception.  Among  one  hundred 
and  forty-nine  cases  of  this  affection  he  found  an  average 
mortality  of  fifty -three  per  cent.  The  first  and  second  days 
showed  mortality  inferior  to  the  general  mortality,  while 
the  four  succeeding  days  showed  a  steadily  increasing  mor- 
tality, in  each  instance  greater  than  the  average.  With 
regard  to  treatment  by  inflation  of  the  bowels  by  enemata 

'  C.  L.  Gibson  :  "Mortality  and  Treatment  of  Acute  Intussusception, 
with  Table  of  239  Cases.  "    Medical  Record.  July  17th,  1897. 


ACUTE  OBSTRUCTION.  267 

of  fluids  (or  air)  Gibson  says :  "  It  is  probably  not  an  ex- 
aggeration to  say  that  if  all  cases  of  intussusception  were 
treated  on  the  onset,  or  say  within  forty -eight  hours,  by 
abdominal  section,  without  any  previous  attempt  at  re- 
duction, the  mortality,  while  still  considerable,  would  in  all 
probability  be  very  much  less  than  the  present  figures." 
Gibson  believes  that  injections  should'  be  tried  only  on 
the  first  or  at  the  latest  on  the  second  day. 

In  the  discussion  on  intestinal  obstruction  which  took 
place  at  the  New  York  State  Medical  Association, '  all  the 
si)eakers  (Parker  Syms,  E.  D.  Ferguson,  George  D.  Stew- 
art, J.  W.  Gouley,  J.  D.  Rushmore,  LeRoy  J.  Brooks, 
John  F.  Erdmann,  Fred.  H.  Wiggin,  and  H.  O.  Marcy) 
were  in  favor  of  surgical  treatment  and  for  early  interven- 
tion. J.  D.  Rushmore  says:"*  "I  have  no  hesitation  in 
affirming  that  in  competent  hands  operation  for  intestinal 
obstruction  would  not  have  a  mortality  above  twenty  per 
cent.  In  my  personal  experience,  including  over  one  hun- 
dred and  ten  operations,  the  mortalit}'  has  been  nearly  forty 
per  cent.  In  the  last  thirty  cases  there  have  been  six 
deaths."  Wiggin'  considers  that  operations  performed 
within  the  first  forty-eight  hours  will  give  a  mortality  of 
22.2  per  cent. 

Inasmuch  as  the  question  of  operation  has  to  be  dealt 
with  in  each  case  of  intestinal  obstruction,  it  is  advisable 
to  have  the  opinion  and  advice  of  an  expert  surgeon  right 
at  the  start  of  the  disease.  The  physician  and  surgeon 
should  act  together,  the  first  watching  the  symptoms 
carefully  and  making  the  diagnosis,  the  second  prepared 
to  resort  to  surgical  intervention  as  soon  as  it  is  demanded. 

'  Transactions  of  the  New  York  State  Medical  Association,  1898. 

2 J.  D.  Rushmore;  Ibidem. 

SF   H.  Wiggiu;  Da  Costa's  "Modern  Surgery."  p.  644. 


268  DISEASES  OF  THE  INTESTINES. 

In  this  way  the  number  of  recoveries  will  be  greater  in  the 
future  than  it  has  been  in  the  past. 

The  operation  consists  in  making  an  abdominal  incision, 
finding  the  seat  of  the  lesion,  and  removing  the  obstacle  if 
possible.  If  not,  an  enterostomy  is  performed  in  the  most 
distended  coil  of  intestine  which  is  then  attached  to  the 
abdominal  wall.  The  fecal  matter  and  the  gases  thus  find 
an  outlet  through  this  opening.  Enterostomy  is  also  re- 
quired in  all  cases  in  which  the  portions  of  the  intestine 
are  already  found  gangrenous.  Treves  says  that  this  oi)er- 
ation  (enterostomy)  could  be  avoided  in  acute  intestinal 
obstruction  if  the  abdomen  were  opened  at  the  very  earliest 
possible  moment.  Every  hour  delayed  adds  to  the  grav- 
ity of  the  case.  "  The  earlier  the  operation  the  less  the 
need  for  enterostomy.  Laparotomy  should  be  performed 
at  an  early  enough  period  to  render  an  opening  into  the 
bowel  unnecessary." 

CHRONIC  INTESTINAL  OBSTRUCTION. 

Etiology. — Chronic  intestinal  obstruction  may  be  caused 
by  the  same  factors  which  produce  acute  ileus  if  they  do 
not  occlude  the  entire  lumen  of  the  bowel  but  leave  part  of 
the  canal  open.  Besides,  obstruction  of  the  intestine  is 
frequently  occasioned  by  strictures  resulting  from  ])reced- 
ing  ulcers  or  from  new  growths.  The  latter,  benign  as 
well  as  malignant,  are  liable  to  give  rise  to  occlusion  even 
if  they  do  not  occupy  the  entire  circumference  of  the  bowel, 
by  simply  obtruding  part  of  the  canal  at  the  site  of  their 
greatest  development.  Strictures  caused  by  ulcers  much 
more  frequently  involve  the  large  than  the  small  intestine. 
According  to  Treves,  they  are  found  six  times  as  often  in 
the  large  bowel  as  in  the  small  one. 

While  formerly  dysentery  was  believed  to  be  the  cause  of  a 


CHRONIC  OBSTRUCTION.  269 

large  number  of  these  intestinal  strictures,  Woodward '  has 
shown  that  this  view  is  not  supported  by  facts.  Among 
the  many  autopsies  on  patients  with  chronic  dysentery 
which  the  latter  had  an  opportunity  to  observe,  there  was 
not  one  case  of  dysenteric  stricture  of  the  intestine. 
Nothnagel  agrees  with  Woodward.  On  the  other  hand, 
tuberculous  ulcers  of  the  intestine  which  were  regarded 
as  only  rare  causes  of  intestinal  stricture  have  recently  been 
found  to  produce  strictures  quite  frequently.  Koenig ''  laid 
stress  upon  the  frequency  of  constricting  tuberculosis  of 
the  intestines.  The  latter  mav  exist  even  if  tuberculosis 
in  other  organs  is  absent.  Ulcers  of  tyiihoid  fever  very 
rarely  if  ever  cause  strictures,  and  this  also  applies  to  the 
small  follicular  ulcers.  Syphilitic  ulcers  on  the  contrary 
produce  strictures  (luite  often.  All  kinds  of  strictures  are 
met  with  most  frequently  in  the  lower  portion  of  the  colon, 
principally  in  the  rectum.  Sometimes  they  lie  just  above 
the  anal  region  and  can  then  be  very  easily  discovered. 

Symptomatology.  — The  symptoms  and  the  course  of  the 
disease  vary  considerably,  and  greatly  depend  upon  the 
cause  of  the  obstruction.  Thus,  clinically,  the  benign 
growths  must  be  differentiated  from  the  malignant  ones 
(in  which  the  obstruction  is  caused  by  cancer).  The  pic- 
ture which  the  intestinal  obstruction  as  such  produces 
will,  however,  be  pretty  much  the  same.  A  stenosis  which 
is  not  very  much  pronounced  may  give  rise  to  no  symp- 
toms whatever.  It  is  therefore  quite  evident  that  the  dis- 
ease may  exist  for  some  length  of  time  before  manifesting 
its  presence. 

In  typical  cases  of  chronic  intestinal  obstruction  the 
onset  is  slow  and  insidious.     The  patient  at  first  notices 

'  Woodward  :  Loc.  cit. 

*  Koenig  :  Deutsche  Zeitsclirift  filr  Chirurgie,  1891, 


270  DISEASES  OF  THE  INTESTINES. 

slight  digestive  disturbances,  some  discomfort  in  the 
abdomen  which  gradually  changes  into  real  pain,  and 
slight  constipation.  The  latter  as  a  rule  quickly  becomes 
worse.  Mild  aperients  which  a  short  while  before  were 
efficient  refuse  to  act,  and  the  patient  is  obliged  to  resort  to 
stronger  cathartics ;  at  times  even  these  will  fail  to  work. 
Frequently  constipation  suddenly  alternates  with  an  attack 
of  severe  diarrhoea,  which  may  last  several  days  and  be 
followed  by  another  period  of  obstinate  constipation.  In 
some  instances  the  color  and  form  of  the  fecal  matter  will 
be  an  indication  of  the  seat  of  the  stenosis.  It  is  gener- 
ally believed  that  pipestem-like  or  tape-like  motions  indi- 
cate a  stricture  in  the  colon.  According  to  Treves, '  how- 
ever, this  sign  is  of  very  little  value,  as  in  the  great 
majority  of  cases  the  sphincter  muscle  is  the  originator 
of  these  peculiar  shapes.  Diarrhcea  may  also  occasionally 
occur.  It  is  sometimes  quite  obstinate,  especially  if  the 
stenosis  is  situated  in  the  large  bowel.  An  admixture  of 
blood  or  pus  in  the  dejecta  is  occasionally  met  with  and  is 
due  to  ulcerative  processes  taking  place  at  the  seat  of  the 
stricture  or  immediately  above  it. 

Vomiting  is  not  a  very  marked  feature  at  first,  but  later 
on  occurs  more  frequently.  When  the  obstruction,  how- 
ever, becomes  complete,  vomiting  is  a  prominent  symp- 
tom and  may  assume  a  stercoraceous  character. 

The  situation  of  the  obstruction  has  much  influence  upon 
the  clinical  picture  of  the  disease.  If  the  stenosis  is  situ- 
ated in  the  duodenum  above  Vater's  papilla,  the  symptoms 
will  resemble  those  of  stricture  of  the  pylorus.  Ischochj^- 
mia,  vomiting,  nausea  will  be  the  prominent  features.  A 
stenosis  of  the  duodenum  below  Yater's  papilla,  although 
presenting  symptoms  similar  to  those  of  stricture  of  the 
'  Treves :  Loe.  cit. .  p.  395. 


CHRONIC  OBSTRUCTION.  271 

pylorus,  will  be  recogiiized  bj^  the  more  or  less  constant  pres- 
ence of  large  amounts  of  bile  in  the  stomach.  The  farther 
down  in  the  small  intestine  the  obstruction  is  situated,  the 
less  pronounced  are  the  gastric  symptoms  and  the  more 
marked  the  intestinal  manifestations  (less  vomiting  or 
nausea,  more  constipation,  colicky  jjains).  If  the  stenosis 
is  situated  in  the  lower  portion  of  the  ileum  or  in  the  colon 
no  gastric  symptoms  are  as  a  rule  present.  The  appetite 
is  good,  there  is  no  nausea,  and  the  principal  features  are 
obstinate  constipation,  sometimes  alternating  with  diar- 
rhoea and  frequent  attacks  of  colicky  pains. 

Condition  of  the  Abdomen.  The  abdomen  may  present  a 
normal  appearance  when  the  stenosis  is  situated  in  the 
upper  portion  of  the  small  intestine,  although  in  some  of 
these  cases  there  may  be  a  protrusion  of  the  upper  part 
of  the  abdomen.  If  the  site  of  obstruction  is  in  the  lower 
portion  of  the  small  intestine  or  in  the  large  bowel,  then 
some  distention  of  the  abdomen  is  usually  noticeable,  espe- 
cially after  the  disease  has  advanced  considerably.  Above 
the  obstruction  there  is  always  distention  and  hypertro- 
phy of  the  bowel.  The  latter  is  a  manifestation  of  the 
attempt  which  nature  makes  in  order  to  overcome  the  diffi- 
culty. The  intestines  above  the  stenosis  act  with  greater 
force  in  order  to  propel  the  contents  through  the  narrow 
passage. 

The  contraction  of  the  bowel  above  the  affected  area 
often  assumes  a  tetanic  type  and  is  then  painful.  Such 
violent  tetanic  contractions  are  often  visible  through  the 
abdominal  wall,  and  by  propelling  large  amounts  of  liquids 
and  gases  through  the  narrowed  lumen,  give  rise  to  gur- 
gling and  bubbling  sounds  audible  at  a  distance.  Treves 
thus  describes  the  picture  which  this  violent  peristalsis 
manifests :  "  The  surface  of  the  abdomen  becomes  uneven, 


272  DISEASES  OP  THE  INTESTINES. 

a  rounded  elevation  appears  in  one  place  and  depressions 
appear  in  another.  Thej  produce  an  aspect  comparable 
to  that  of  a  relief  map  of  a  hilly  country .  Slowly  the 
hill-like  elevation  sinks  and  vanishes  and  out  of  the 
shallow  valley  appear  fresh  eminences  which  rise  up  and 
move  along  beneath  the  skin.  The  movements  are  slow 
and  attended  by  colicky  pains,  and  by  more  or  less  of 
rumbling  and  gurgling  sounds."  .  .  .  "The  same  coil 
appears  again  and  again  and  can  often  be  quite  definitely 
recognized.  Although  as  a  rule  the  contracting  coils  of 
the  small  intestine  are  of  considerably  smaller  size  than 
those  of  the  large  bowel,  occasionally  even  the  small  intes- 
tine may  assume  such  dimensions  that  it  cannot  be  differ- 
entiated from  the  large  bowel." 

Meteorism  is  often  present.  If  the  obstruction  is  situ- 
ated in  the  lower  portion  of  the  colon  or  in  the  rectum,  the 
meteorism  is  at  first  restricted  to  the  large  bowel,  the  dis- 
tention then  being  pronounced  along  the  course  of  the  colon 
at  both  sides  of  the  abdominal  wall  and  in  the  epigastric 
region.  The  lower  part  of  the  abdomen  and  also  the  re- 
gion of  the  navel  may  be  free  from  meteorism.  If  the 
stricture  is  situated  in  the  lower  portion  of  the  ileum  or 
caecum,  the  lumbar  regions  of  the  abdomen  are  quite  lax, 
while  the  distention  is  more  or  less  pronounced  in  the  me- 
sogastric  and  hypogastric  regions. 

After  having  described  the  symptoms  of  chronic  intesti- 
nal obstruction  in  a  general  way  it  will  be  useful  to  point 
out  separately  the  characteristics  of  some  special  forms 
which  occur  more  or  less  frequently. 

Chronic  intussusception  may  develop  either  after  an  acute 
attack  or  begin  slowly  and  insidiously  without  at  first  giv- 
ing rise  to  any  marked  symptoms.  It  is  most  fre(juently 
found  in  the  ileo-csBcal  portion.     Pain  occurs  during  the 


CHROFIC  OBSTRUCTION.  273 

progress  of  the  disease  and  is  usually  of  a  paroxysmal 
character.  Attacks  of  pain  may  appear  several  times  a 
day  or  once  in  twenty-four  hours.  Occasionally  days  and 
even  weeks  elapse  between  the  paroxysms.  As  a  rule  the 
intervals  between  the  attacks  grow  shorter  as  the  disease 
advances.  In  some  cases  there  is  almost  continuous  suffer- 
ing with  occasional  exacerbations.  "Vomiting  seldom  oc- 
curs and  is  certainlj-^  not  a  marked  feature.  A  tendency  to 
diarrhoea  very  often  exists.  The  bowels  may  be  normal  or 
constijjated  for  a  while  and  then  become  loose,  or  there 
may  be  persistent  diarrhoea.  Blood  is  very  often  passed 
with  the  stools  and  tenesmus  is  occasionally  present. 

On  examination  of  the  abdomen  by  palpation  a  tumor  is . 
found  in  almost  half  of  the  cases.  The  nature  of  the  tumor 
corresponds  to  that  found  in  acute  intussusception  de- 
scribed above.  Occasionally  a  tumor  can  be  felt  in  the  rec- 
tum when  the  intussusception  involves  the  lower  portion  of 
the  large  bowel.  In  rare  instances  the  invaginated  portion 
is  separated  from  the  bowel  by  necrotic  processes,  and  may 
then  appear  in  the  movement.  Wliile  this  event  may  in 
rare  instances  lead  to  perfect  recovery  (the  other  portions 
of  the  bowel  growing  together  and  the  lumen  thus  being 
restored),  in  the  greater  majority  it  causes  death  through 
perforation,  rupture  of  the  intestinal  walls,  and  general 
peritonitis. 

Chronic  Obstruction  Due  to  Fecal  Accumulation.  This 
variety  of  intestinal  obstruction  is  more  common  in  fe- 
males than  in  males  and  is  usually  met  with  in  more  ad- 
vanced age  and  in  patients  suffering  from  hysteria  and 
brain  troubles.  As  a  rule,  the  patients  have  already  long 
before  been  subject  to  habitual  constipation ;  usually  many 
days  elapse  without  an  evacuation  of  the  bowels.  From 
time  to  time  enormous  quantities  of  fecal  matter  are  passed 
18 


274  DISEASES  OF  THE  INTESTINES. 

by  artificial  means.  Later  on  the  symptoms  of  constipa- 
tion grow  more  intense.  The  abdomen  becomes  distended 
and  it  is  much  more  difficult  to  secure  an  evacuation  even 
by  artificial  means.  As  a  rule  the  patient  is  tormented  by 
eructations  and  flatulence.  His  appetite  is  poor ;  he  has 
a  bad  taste  in  his  mouth  and  frequently  his  breath  has  an 
unpleasant  odor.  Headache,  vertigo,  and  a  general  tired 
feeling  are  often  encountered. 

These  symptoms,  as  well  as  the  marked  unhealthy  ap- 
pearance of  the  skin,  are  most  probably  due  to  intestinal 
auto-intoxication.  Certain  chromogens,  the  products  of 
decomposition,  are  absorl^ed  from  the  bowel  and  give  rise 
,  to  this  peculiar  discoloration  of  the  skin.  The  conjunctivae 
also  are  often  yellow.  A  further  symptom  due  most  prob- 
ably to  the  same  process  of  auto-intoxication  is  the  rise  of 
temperature  which  is  often  present.  If  the  distention  of 
the  abdomen  is  very  marked,  a  feeling  of  oppression  in  the 
chest  and  palpitations  of  the  heart  are  experienced. 

Fecal  accumulation  sometimes  causes  pressure  upon  the 
lumbar  or  sacral  nerves  and  gives  rise  to  discomfort  in 
the  genital  organs  or  to  pain  in  the  thigh  radiating  down 
the  entire  leg.  Distended  coils  may  be  visible  through 
the  abdomen  and  there  may  be  much  rumbling  and  gur- 
gling heard  after  constipation  has  lasted  a  long  period. 
This  symptom  is,  however,  not  so  marked  here  as  in  cases 
of  stricture  of  the  intestine.  Vomiting  may  occur  and  even 
become  stercoraceous.  Slight  colicky  pains  are  felt  over 
the  abdomen,  but  as  a  rule  they  are  not  intense. 

The  symptoms  having  advanced  to  an  extreme  degree,  re- 
lief may  ensue  either  spontaneously  or  after  resort  to  diflFer- 
ent  procedures  which  serve  to  evacuate  the  bowels.  Occa- 
sionally, however,  an  evacuation  of  the  bowel  cannot  be 
obtained  and  the  patient  develops  all  the  symptoms  of  an 


CHRONIC  OBSTRUCTION.        .  276 

unyielding  obstruction  which  may  be  fatah  Often  there 
are  attacks  of  obstruction  following  each  other  at  certain 
intervals.  The  narrowed  lumen  of  the  bowel  most  prob- 
ably becomes  entirely  occluded  or  blocked  by  a  piece  of 
hard  fecal  matter,  which  completely  fills  it  and  cannot 
move  in  either  direction.  Sometimes  the  abrupt  stoppage 
may  be  due  to  some  bending  or  kinking  of  the  distended 
bowel. 

In  almost  all  cases  of  obstruction  by  fecal  masses 
a  tumor  can  be  palpated  usually  in  some  portion  of  the 
colon.  The  tumor  is  caused  by  the  fecal  accumulation. 
The  caecum,  the  hepatic  and  the  sigmoid  flexures  are  the 
places  where  the  tumor  is  most  often  encountered.  Such 
a  fecal  tumor  feels  hard  and  uneven ;  sometimes  it  has  a 
globular  shape.  As  a  rule  it  is  not  painful  on  pressure. 
Sometimes  it  is  possible  to  change  the  shape  of  the 
tumor  by  pressure.  This  is  the  best  proof  of  its  fecal 
character.  Sometimes,  however,  pressure  does  not  give 
rise  to  any  change  in  the  configuration  of  the  mass  if 
the  fecal  matter  is  very  hard.  The  best  sign  of  its  fecal 
nature  is  the  change  in  form  after  repeated  irrigations  of 
the  bowel.  In  some  rare  instances  the  fecal  accumulation 
occupies  the  greater  part  of  the  abdominal  cavity  and  gives 
the  impression  of  one  immense  tumor  of  very  hard  consist- 
ency. I  have  seen  two  such  cases  in  patients  suffering 
from  grave  melancholia.  Here  also  after  repeated  irriga- 
tions of  the  bowel  and  administration  of  cathartics  the  tu- 
mor gradually  becomes  smaller  and  ultimately  disa]>poars. 

Stricture  of  the  Rectum. — In  this  condition  as  a  rule  there 
are  at  first  merely  symptoms  of  constipation ;  later  on  these 
become  more  obstinate,  requiring  stronger  cathartics.  The 
patient  now  begins  to  complain  of  congestion  of  the  head, 
anorexia,  nausea,  cold  feet,  and  sometimes  of  disagreeable 


276  DISEASES  OF  THE  INTESTINES. 

sensations  in  his  limbs ;  still  later  there  is  diarrhoea  which 
may  persist  as  such  or  alternate  with  constipation.  Off 
and  on  muco-purulent  material  appears  with  the  dejecta. 
A  burning  sensation  is  often  felt  in  the  rectum,  and  tenes- 
mus is  frequently  present.  Hemorrhoids  and  prolapse  of 
the  rectum  often  accompany  the  stricture. 

Digital  examination  of  the  rectum  often  reveals  a  ste- 
nosed  area  in  its  lower  part.  The  finger  is  either  not  able 
to  pass  any  farther  than  a  few  centimetres  (five  to  six) 
above  the  anus  or  it  meets  with  a  resistance  which  it  can 
overcome.  Contrary  to  spasm  of  the  rectum  which  yields 
completely  after  the  finger  has  succeeded  in  passing  the 
constriction,  in  stricture  of  the  rectum  the  pressure  of  the 
narrowed  lumen  exerted  upon  the  finger  remains  constantly 
the  same. 

Most  of  the  strictures  are  situated  about  five  to  six  centi- 
metres above  the  anus,  seldom  higher  up.  In  the  latter  in- 
stance the  examination  must  be  made  with  a  bougie  or  with 
a  rubber  tube  which  is  not  too  soft.  In  order  to  determine 
the  exact  nature  of  the  stricture  it  is  always  best  to  make 
a  visual  examination  of  the  rectum  by  means  of  a  specu- 
lum. 

CompUcatio)is. — No  matter  to  what  cause  the  intestinal 
obstruction  is  due,  in  the  protracted  course  of  the  disease 
several  complications  are  liable  to  occur,  although  here 
less  often  than  in  acute  obstruction.  Above  the  stenosed 
area  ulcerations  of  the  bowel  may  take  place  and  perfora- 
tion may  occur,  giving  rise  to  general  peritonitis.  Occa- 
sionally circumscribed  peritonitis  may  ensue  in  a  similar 
manner  and  lead  to  an  abscess  surrounded  by  adhesions. 
Such  an  abscess  may  rupture  through  the  abdominal  wall 
and  under  favorable  conditions  (if  communicating  with 
the  intestinal  lumen)  form  a  fecal  fistula.     In  many  in- 


CHRONIC  OBSTRUCTION 


277 


stances  the  patients  gradually  waste  away  and  die  in  con- 
sequence of  thrombosis  of  the  crural  vein  and  decubitus. 

Course  and  Prognosis. — The 
duration  of  chronic  intestinal 
obstruction  depends  largely 
upon  the  nature  of  the  partic- 
ular affection  and  upon  the 
degree  of  the  obstruction.  If 
there  are  no  comjjlications  and 
the  patients  lead  a  perfectly  ra- 
tional life  (with  regard  to  diet 
and  treatment)  the  condition 
may  last  a  number  of  years.  In 
other  cases  the  symptoms  of 
intestinal  obstruction  rapidly 
progress  and  life  is  then  of 
short  duration  unless  something 
radical  is  done. 

Diagnosis. — The  diagnosis  of 
chronic  intestinal  obstruction  is 
warranted  by  the  presence  of 
gradually  increasing  sjmptoms 
of  constipation,  and  attacks  of 
intestinal  colic  with  a  temporary 
stoppage  of  the  bowels  follow- 
ing each  other  at  not  too  great 
intervals.  The  acute  attack  of 
obstruction  in  these  cases  of 
chronic  intestinal  stenosis  is  as  a  rule  much  milder  than 
in  acute  occlusion  of  the  bowel  not  due  to  a  chronic  con- 
dition. In  the  chronic  form  there  is  either  no  collapse  at 
all  or  it  is  but  slightly  marked.  Increased  intestinal  peri- 
stalsis is  often  encountered  in  the  chronic  form,  especially 


S 


Fig.  3<>.— Patient  M.  with  Chronic 
Intestinal  Stenosis  (Stricture  of 
Descending  Colon),  Showing  the 
Barrel-shaped  Abdomen. 


278  DISEASES  OF  THE  INTESTINES. 

during  an  attack  of  obstruction,  while  in  the  acute  form 
this  is  quite  rare  and,  if  present,  less  pronounced.  The 
barrel-shape  of  the  abdomen  is  often  present  in  chronic 
intestinal  stenosis  and  is  of  diagnostic  value  (Fig.  36). 
The  different  forms  of  intestinal  obstruction  can  be  rec- 
ognized by  their  varied  symptoms  which  have  alreadj* 
been  described  above. 

Treatment. — The  treatment  comprises  the  management 
of  the  disease  during  the  intervals  and  during  the  attacks. 
During  the  intervals  the  following  rules  are  of  importance : 
The  diet  should  exclude  all  substances  which  give  large 
residue  of  fecal  matter  or  which  are  of  an  irritating  charac- 
ter. Thus  green  vegetables,  salads,  fruits,  vinegar,  mus- 
tard, pepper,  must  be  strictly  forbidden.  Milk  and  milk 
soups,  eggs,  tender  meats  without  too  much  fat  and  with- 
out tendons,  butter,  toasted  bread  or  plain  white  bread 
well  baked,  farina,  rice  and  sago,  well  cooked,  are  permis- 
sible. The  patients  should  eat  frequently  and  not  too 
much  at  a  time.  Cold  drinks  should  be  avoided.  Atten- 
tion must  be  paid  to  the  patient's  taking  a  sufficient  quan- 
tity of  food. 

The  bowels  must  be  kept  in  working  order.  It  is  abso- 
lutely necessary  to  secure  one  evacuation  daily.  Massage, 
electricity,  and  the  usual  mild  cathartics  (like  magnesia 
sul5)hate,  rhubarb,  cascara  sagrada,  syrup  of  figs)  may  be 
used.  Injections  of  water  or  oil  into  the  bowel  are  also 
of  benefit.  When  diarrhoea  is  i^resent  it  should  not  be 
checked  unless  the  patient  is  greatly  debilitated.  Even 
then  only  mild  astringent  remedies  are  permissible.  Often 
even  during  periods  of  diarrhoea,  when  not  very  large  evac- 
uations take  place,  a  mild  cathartic  (like  castor  oil  or 
Carlsbad  salts)  must  be  employed  in  order  to  assure  a 
thorough  cleansing  of  the  bowel. 


CHRONIC  OBSTRUCTION.  279 

During  the  attack  of  intestinal  colic  warm  fomentations 
over  the  abdomen  should  be  applied.  If  these  be  insuffi- 
cient, the  narcotic  remedies  are  in  place.  Opium  alone  or 
opium  with  belladonna  ma}'  be  given  either  by  the  mouth 
or  in  suppositories.  Here  also  it  is  necessary  to  produce 
a  sufficient  evacuation  of  the  bowel,  which  is  best  done  by 
rectal  injections.  If  there  are  great  distention  of  the  abdo- 
men and  vomiting,  gastric  lavage  is  beneficial.  Cocaine 
in  doses  of  one-third  to  one-half  grain,  or  menthol  one 
grain  three  times  daily,  will  allay  the  vomiting.  If  there 
is  a  real  attack  of  acute  obstruction  this  must  be  treated 
in  the  same  manner  as  primary  acute  intestinal  obstruc- 
tion, described  above. 

If  the  stenosis  involves  the  upper  portion  of  the  small 
intestine,  lavage  will  play  an  important  part  in  allaying 
the  symptoms  temporaril}'.  Chronic  fecal  impaction  re- 
quires the  application  of  massage  and  also  of  electricity, 
as  described  in  the  chapter  on  constipation.  Sometimes 
the  hardened  scybala  will  have  to  be  removed  from  the 
rectum  by  artificial  means.  For  this  purpose  the  sphincter 
is  first  dilated  and  the  fecal  masses  are  removed  with  the 
fingers  or  with  a  spoon-shaped  instrument.  If  there  is  a 
blocking  of  the  passage  higher  up  in  the  colon,  strong 
cathartics  (croton  oil)  may  be  administered.  Metallic 
mercury  has  also  been  advantageously  used  in  these  in- 
stances. 

Strictures  of  the  rectum,  excepting  those  of  a  cancerous 
nature,  can  first  be  treated  by  dilating  them  gradually  with 
bougies  of  various  size.  The  rectal  bougie  of  Crede  best 
answers  this  purpose.  It  is  advisable  to  leave  the  bougie 
within  the  stricture  for  at  least  fifteen  minutes  and  to 
insert  it  once  every  two  to  three  days.  If  the  stricture  is 
of  a  very  high   degree  this  method  of  treatment  may  be 


280  DISEASES  OF  THE  INTESTINES. 

inefficient,  and  then  surgical  measures  will  have  to  be  un- 
dertaken. 

Operative  Intefi'vention. — All  types  of  chronic  intestinal 
obstruction,  with  the  exclusion  of  those  caused  by  fecal 
accumulation  and  strictures  of  the  rectum,  gradually  grow 
worse.  The  above-described  modes  of  treatment  are  only 
of  a  palliative  nature.  For  this  reason  it  must  be  consid- 
ered as  a  decided  advance  that  surgical  means  have  been 
found  fully  to  remove  the  obstacle  and  restore  the  patient 
to  complete  health.  The  procedures  which  are  resorted 
to  are  various  and  depend  upon  the  anatomical  lesion  un- 
derlying the  obstruction. 

Malignant  growths  must  be  extirpated  as  early  as  pos- 
sible and  an  end-to-end  anastomosis  of  the  bowel  estab- 
lished. A  circular  stricture  of  the  bowel  (of  benign  type) 
can  be  removed  by  enteroplast}'  in  a  similar  way  as  pylo- 
roplasty, namely,  by  splitting  the  gut  parallel  to  its  axis 
or  vertically  to  the  stricture  and  uniting  the  edges  of  the 
incision  transversely.  Pean '  has  successfully  performed 
such  operations.  Several  simple  strictures  of  the  bowel 
can  be  treated  in  the  same  way,  if  they  are  not  too  close 
together.  If  the  stricture  is  of  a  tubular  form  or  if  it  is 
of  too  high  a  degree,  excision  of  the  involved  part  followed 
by  exact  coaptation  of  the  divided  ends  by  sutures  is  best 
done.  This  operation  is  greatly  facilitated  by  Murphy's 
button,  which  makes  it  possible  to  unite  the  two  ends  of 
the  severed  bowel  rapidly  without  losing  too  much  time 
in  the  suturing. 

In  cases  in  which  the  stricture  cannot  be  excised  nor 

otherwise  remedied,  or  in  any  other  form  of  obstruction  of 

the  bowel  which  cannot  be  removed,  the  bowel  just  above 

the  stricture  is  united  to  the  bowel  below  it  and  a  short 

'  Pean  .  Bulletin  de  I'Academie  de  Medecine,  1890,  p.  856. 


CHRONIC   OBSTRUCTION.  281 

circuit  thus  established.     This  is  likewise  best  accom- 
plished by  Murphy's  button. 

In  some  strictures  of  the  colon  in  patients  who  are  already 
quite  prostrated,  a  complete  operation  of  excision  or  even 
of  the  formation  of  a  new  circuit  cannot  be  performed  with- 
out too  great  risk  of  life.  Here  colotomy  is  indicated, 
being  later  supi^lemented  by  a  more  radical  procedure 
when  the  patient  is  stronger  and  in  better  condition. 

Adhesions  should  be  severed  and  tumors  compressing 
the  bowel  treated  by  radical  removal.  Surgical  treatment 
of  the  intestinal  stenosis,  affording  as  it  does  radical  re- 
lief, should  be  resorted  to  in  every  case  as  soon  as  the 
diagnosis  is  positive.  The  only  excuse  for  subjecting  the 
patients  to  non-operative  measures  as  long  as  they  get  along 
in  comparative  comfort,  is  the  high  mortality  which  surgi- 
cal intervention  still  furnishes.  According  to  Treves, '  the 
mortality  fluctuates  between  twelve  and  twenty  per  cent. 
It  is  to  be  hoped,  however,  that  owing  to  our  advanced 
knowledge  of  this  subject  the  diagnosis  of  intestinal  ste- 
nosis will  be  made  quite  early,  and  that  the  patients  by 
being  operated  upon  at  an  early  period  will  show  a  smaller 

percentage  of  mortality. 

'  Loc.  cit.,  p.  560. 


CHAPTER  X. 

NEKVOUS  AFFECTIONS  OF  THE  INTESTINES. 

Generar Remarks. — The  intestinal  tract  is  rich  in  gangli- 
onic cells  and  nerves.  The  plexus  mesentericus  Auerbach 
and  the  plexus  entericus  Meissner  accompany  it  through 
its  entire  length.  The  vagus  and  the  splanchnic  nerves 
surround  the  intestinal  canal  with  numerous  branches  and 
form  ramifications  with  the  ganglionic  plexus.  Although 
a  thorough  knowledge  of  the  exact  a(?tion  of  these  different 
nerve  groups  has  not  yet  been  acquired,  still  we  are  certain 
that  they  govern  the  secretory,  absorptive,  and  motor 
functions  of  the  intestinal  canal. 

Secretion  seems  to  be  dependent  a  great  deal  upon  the 
ganglionic  plexus,  as  can  be  learned  from  Moreau's '  ex- 
periment. This  investigator  ligated  an  intestinal  coil  and 
severed  all  the  nerves  belonging  to  it.  In  a  few  hours  the 
coil,  thus  treated,  was  found  filled  with  a  fluid  showing 
amylolytic  qualities  and  containing  small  quantities  of 
albumin.  In  order  to  prove  the  secretory  influence  of 
nerves  upon  the  intestines  Fleischer''  justly  refers  to 
the  fact  demonstrated  by  Quincke,  Demant,  and  Mass- 
loff, '  that  in  man  as  well  as  in  animals  after  ingestion  of 
food  into  the  stomach,  secretion  takes  place  in  the  lower 
part  of  the  intestine,  long  before  the  arrival  of  the  chyme. 

'  Moreau :  Centralbl.  f.  die  nied.  Wissensch..  1868.  No.  14. 
'  R.  Fleischer:  "Krankheiten  des  Darms,"  Wiesbaden,  1896. 
'Massloflf:  "  Untersuchungen  aus  dam  physiologischen  Institut  zu 
Heidelberg. "  Bd.  ii. 


NERVOUS  AFFECTIONS  OF  THE  INTESTINES.       283 

This  also  shows  that  the  nerves  of  the  intestinal  tract  are 
influenced  by  reflex  action  from  the  nerves  or  the  stomach. 

Vasomotor  nerve  filaments  have  also  been  proven  to 
exist  in  the  intestines.  Thus  stimulation  of  the  splanch- 
nic nerve  causes  a  contraction,  while  its  section  is  followed 
bj'  dilatation  of  the  intestinal  blood-vessels.  These  vaso- 
motor nerve  filaments  are  undoubtedly  also  much  con- 
cerned with  absorption. 

The  motor  function  of  the  nerves  and  their  influence  upon 
peristalsis  have  been  studied  in  an  exhaustive  manner  by 
Nothnagel,  Brahm-Houkgeest,  and  others,  and  have  been 
described  in  the  chapter  on  physiology  (page  28). 

Although  under  normal  conditions  we  scarcely  perceive 
any  sensations  within  the  intestinal  tract,  wp  are  neverthe- 
less certain  that  sensory  filaments  exist  in  the  nervous  ap- 
paratus of  the  intestines.  This  is  revealed  by  the  fact  that 
the  action  of  some  stimuli  of  greater  intensity  than  normal 
upon  the  intestinal  wall,  gives  rise  to  sensations  of  pain 
and  pressure.  Thus,  a  person  not  accustomed  to  a  coarse 
diet,  after  ingestion  of  a  large  quantity  of  cabbage  and 
beans,  for  instance,  may  suff'er  after  six  to  eight  hours 
from  pains  in  the  lower  part  of  the  abdomen  caused  by  the 
undue  irritation  of  tlie  small  intestine.  In  pathological 
conditions  the  sensory  character  of  the  intestinal  uerves 
is  evinced  very  frequently.  In  fact  this  is  one  of  the  im- 
portant points  which  we  have  to  consider  in  almost  any 
affection  of  the  intestinal  canal. 

The  neuroses  of  the  intestine  may  be  classified  into :  1, 
motor  neuroses;  2,  sensory  neuroses;  and  3,  secretory 
neuroses.  Very  often  these  different  neuroses  exist  in 
combination.  Thus,  a  motor  neurosis  may  exhibit  fea- 
tures belonging  to  secretory  or  sensory  derangements. 
The  designation  of  the  neurosis,  however,  should  depend 


284  DISEASES  OF  THE  INTESTINES. 

upon  the  type  most  prevalent.  All  affections  of  the  intes- 
tines in  which  no  anatomical  lesion  can  be  discovered  are 
classified  as  neuroses  or  functional  diseases  of  the  intes- 
tines. 

Intestinal  neuroses  may  be  primary,  i.e.,  the  affection 
emanates  from  the  intestinal  tract,  or  they  may  be  second- 
ary, occurring  in  connection  with  nervous  manifestations 
in  other  organs.  Etiologically  we  know  that  psychical 
influences,  mostly  of  a  depressing  nature,  as  fear,  fright, 
worry  and  anxiet}',  are  often  the  causative  factors  of  intes- 
tinal neuroses.  Neurasthenia  and  hysteria  as  well  as  a 
general  neurotic  tendency  are  also  liable  to  produce  ner- 
vous affections  of  the  intestinal  tract.  In  some  instances 
the  latter  conditions  are  due  to  a  reflex  action  originating 
from  some  other  diseased  organ  (stomach,  the  genito-uri- 
nary  tract,  uterus,  etc.). 

MOTOR  NEUROSES  OF  THE  INTESTINES. 
IHa)Th(jea. 

Etiology  and  Symptomatology. — Diarrhoea,  meaning  too 
frequent  and  usually  too  watery  movements  of  the  bowels, 
is  always  due  to  increased  intestinal  peristalsis.  Diar- 
rhoea may  be  the  result  of  various  morbid  conditions  of  the 
intestines,  but  here  we  shall  describe  the  form  of  diarrhoea 
which  exists  without  any  apparent  anatomical  lesions. 

Diarrhoea  may  be  classed  under  three  groups:  1.  Ner- 
vous diarrhoea  (Trousseau).'  2.  Dyspeptic  diarrhoea.  3. 
Stercoral  diarrhoea. 

1.  Nervous  Dian'hoea.  Although  all  the  three  groups  of 
diarrhoea  are  primarily  produced  by  increased  peristaltic 
action  of  the  bowels  which  is  in  turn  caused  by  exagger- 
•  Trousseau  :  "Clinique  de  I'Hotel  Dieu,  "  Bd.  ii. 


DIARRH(EA.  285 

ated  action  of  the  nervous  apparatus,  this  group  is  desig- 
nated as  nervous  diarrhoea  on  account  of  the  predominance 
of  the  nervous  element.  Trousseau  was  the  first  to  de- 
scribe nervous  diarrhoea.  It  originates  either  through 
undue  stimulation  of  the  accelerating  jjeristaltic  nerves  or 
through  some  nervous  influences  which  cause  a  serous 
transudation  into  the  intestinal  canal.  Frequently  both 
factors  are  probably  implicated. 

In  many  cases  the  stimulus  may  emanate  from  the  centre 
and  reach  the  intestinal  ganglia  through  the  vagus,  the  sym- 
pathetic, or  the  splanchnic.  In  some  cases,  however,  the 
stimulus  affects  the  ganglionic  cells  of  the  intestinal  wall 
directly.  As  characteristic  instances  of  nervous  diarrhoea 
we  would  mention  those  cases  in  which  there  are  several 
watery  evacuations  after  a  strong  emotion,  thus  after  fright 
or  fear.  Here  the  stimulus  arises  in  the  brain  centres 
supervising  intestinal  motions.  While  in  these  instances 
we  have  to  deal  with  an  acute  transitory  condition,  nervous 
diarrhoea  can  also  appear  in  a  chronic  form  (Nothnagel, 
Peyer").  There  are  persons  who  are  attacked  with  diar- 
rhoea as  soon  as  they  are  in  a  place  where  a  toilet-room  is 
inaccessible.  They  may  then  be  seized  with  abdominal 
pains,  tenesmus,  and  diarrhoea.  In  other  persons,  again, 
the  mere  sight  of  a  water-closet  evokes  an  intense  desire 
for  an  evacuation. 

Occasionally  the  diarrhoea  is  preceded  by  several  other 
nervous  symptoms,  as  for  instance  vertigo,  giddiness,  con- 
gestion of  the  head,  a  sensation  of  heat  all  through  the 
body,  fright,  shortness  of  breath,  or  palpitation  of  the 
heart.  All  these  symptoms  as  a  rule  rapidly  disappear 
after  a  satisfactory  movement. 

"  A.  Peyer  :  "  Die  nervOsen  Affectionen  des  Darmes  bei  der  Neurasthe- 
nie  des  mannlichen  Geschlechts.  "     Wieuer  Klinik,  1893.  Heft  1. 


286  DISEASES  OF  THE  INTESTINES. 

This  form  of  diarrhoea  is  found  in  persons  suffering 
from  neurasthenia  or  hysteria,  in  debilitated  persons,  or 
in  perfect!}'  healthy  people  after  a  more  or  less  pronounced 
shock  to  the  nervous  system.  Moreover  it  is  met  with 
accompanying  affections  of  the  spine.  Thus  Charcot  de- 
scribed attacks  of  diarrhoea  appearing  jjeriodically  in  tabes 
dorsalis  (intestinal  crises).  Lastly,  nervous  diarrhoea  may 
exist  as  a  reflex  condition  in  consequence  of  abnormal  proc- 
esses in  the  neighboring  organs  (the  genito-urinary  tract, 
uterus,  etc.). 

As  an  instance  of  nervous  diarrhoea  the  following  case 
may  be  described : 

N.  S.,  thirty  years  old,  physician,  was  always  perfectly 
well.  After  a  year  of  hard  study  and  a  great  deal  of  care 
and  anxiety  he  had  begun  to  suffer  from  frequent  loose 
evacuations  during  the  last  six  months.  As  a  rule  the 
patient  had  one  or  two  passages  a  few  minutes  after  each 
meal.  Preceding  the  evacuation  rumbling  noises  were 
heard  in  the  lower  part  of  the  abdomen,  while  a  slight 
feeling  of  discomfort  was  experienced.  The  movements 
were  softer  and  more  watery  than  usual,  but  did  not  cou- 
tain  anything  abnormal  (no  mucus,  no  undigested  food). 
The  patient  felt  perfectly  well  in  ever^'  respect,  had  a  good 
appetite,  slept  well,  and  had  not  lost  weiglit.  Exami- 
nation of  the  gastric  contents  showed  the  stomach  to  be 
perfectly  normal.  The  patient  was  given  no  medicines  and 
was  instructed  to  respond  to  nature's  call  in  the  morning 
and  to  try  to  suppress  the  evacuations  after  meals  when- 
ever possible.  For  the  first  few  days  he  succeeded  in  hav- 
ing no  movement  after  some  of  the  meals,  and  gradually 
after  a  few  weeks  was  perfectly  free  from  the  desire  to 
evacuate  the  bowels  after  eating. 

The  following  case  is  reported  by  Fischel : ' 

A  lady,  twenty-three  years  old,  complained  of  a  feeling 
'  P.  Fischel  :  Praerer  med.  Wocheuschr. .  1891. 


DIARRHCEA.  287 

of  oppression,  cardiac  palpitation,  and  severe  attacks  of 
diarrhoea,  which  appeared  periodically  independent  of  the 
quality  of  the  food.  The  passages  were  watery  and  of  a 
strong  alkaline  reaction,  smelled  bad,  and  contained 
triple  phosphate  and  considerable  amounts  of  intestinal 
ei)ithelial  cells.  The  examination  revealed  a  retroflexion 
of  the  uterus.  After  insertion  of  a  pessary  the  diarrhoea 
ceased. 

The  diarrhoea  appearing  after  exposure  to  cold  and  wet 
weather  is  most  probably  caused  by  a  reflex  emanating 
from  the  nerves  of  the  skin  and  producing  hypersemia  of 
the  intestines.  The  latter  gives  rise  to  transudation  into 
the  lumen  of  the  bowel  and  also  to  increased  peristalsis. 
This  form  of  diarrhoea  disappears  very  quickly  (in  twelve 
to  twenty -four  hours)  and  does  not  produce  any  anatomi- 
cal changes  of  the  intestinal  walls. 

Another  group  of  diarrhoeas  takes  its  origin  from  an  irri- 
tation of  the  intestinal  nerves  through  some  abnormal  sub- 
stances contained  iu  the  blood.  The  cathartic  action  of 
some  remedies  subcutaneouslj'  injected  is  the  best  proof 
of  this  possibility.  The  diarrhoea  occurring  in  cases  of 
septicaemia,  of  nephritis  (with  or  without  ursemic  symp- 
toms), and  also  diabetes  is  best  explained  b^'  the  theory 
of  irritating  products  circulating  in  the  blood.  The  diar- 
rhoea accompanying  typhoid  fever  and  dysenterj-  iu  the 
first  stage  before  there  has  been  time  for  the  formation  of 
ulcers,  is  caused  by  the  circulating  iu  the  blood  of  toxic 
elements  produced  by  the  pathogenic  micro-organisms. 

2.  Dyspeptic  Diarrhoea.  Under  dyspeptic  diarrhoea  may 
be  comprised  (a)  the  diarrhcea  which  appears  after  certain 
articles  of  food;  (h)  diarrhoea  accompanying  abnormal 
conditions  of  the  gastric  contents. 

(a)  Certain  foods  may  cause  mushy  or  watery  evacua- 
tions, as,  for  instance,  fresh  fruit,  cucumbers,  cabbage,  and 


288  DISEASES  OF  THE  INTESTINES. 

beets.  The  liability  to  diarrhcea  from  these  foods,  how- 
ever, greatly  varies  in  different  persons.  In  some  people 
milk  produces  diarrhoea,  while  in  others  it  is  rather  con- 
stipating. 

(6)  Pronounced  conditions  of  subacidity  of  the  gastric 
contents  and  still  oftener  achylia  gastrica  are  associated 
with  diarrhoea.  Here  probablj'^  the  chyme  on  account  of 
its  not  having  undergone  any  considerable  changes  in  the 
stomach  exerts  mechanically  too  great  a  stimulus  on  the 
intestinal  wall  and  thus  causes  the  increased  peristalsis. 
Hyperchlorhydria,  although  rarely,  is  also  found  associ- 
ated with  diarrhoea.  Here  the  chyme  containing  too  much 
acid  most  probably  produces  the  increased  peristalsis. 

3.  Stercoral  Diarrhcea.  Stercoral  diarrhoea  means  a  diar- 
rhoea arising  in  consequence  of  too  great  a  stimulus  from 
fecal  matter. 

Etiology  and  Symptomatology. — If  healthy  persons  for 
some  cause  or  other  become  constipated  for  a  certain  pe- 
riod of  time,  the  constipation  may  be  followed  by  diar- 
rhoea. The  latter  is  generally  produced  by  the  formation 
of  certain  gases  which  chemically  or  mechanically  exert  a 
stronger  stimulus  upon  the  intestinal  peristalsis.  Occa- 
sionally hard  scybala,  as  such,  irritate  the  mucous  mem- 
brane of  the  bowel  too  much  and  cause  increased  secretion 
and  peristalsis.  In  stercoral  diarrhoea  the  evacuations  are 
as  a  rule  at  first  formed  and  solid,  later  mushy  and  watery. 
Off  and  on  these  watery  passages  contain  several  small 
scybala  as  hard  as  a  stone.  Shortly  before  the  appearance 
of  diarrhoea  the  abdomen  is  often  quite  bloated  and  borbo- 
rygmi  are  heard  in  the  intestines.  The  patients  very  fre- 
quently complain  of  intense  headaches.  The  passage  of 
bad  smelling  flatus  affords  only  temporary  relief,  while  a 
good  movement  removes  almost  all  the  symptoms.     Slight 


DIARRHCEA.  289 

gastric  symptoms  may  accompany  this  condition.  A  ra- 
tional diet  effectually  arrests  the  diarrhoea,  but  after  an- 
other period  of  constipation  it  may  reappear,  and  if  this 
happens  very  frequently,  intestinal  catarrh  may  be  the 
result. 

Diagnosis. — The  diagnosis  of  nervous  diarrhoea  can  be 
made,  if  anatomical  lesions  of  the  intestines  can  be  ex- 
cluded and  if  the  passages  do  not  contain  a  considerable 
amount  of  mucus.  The  special  tj'pe  of  the  diarrhoea  may 
be  determined  either  by  the  symptoms  (nervous  diarrhoea 
proper,  stercoral  diarrhoea)  or  by  an  examination  of  the 
gastric  contents  (dyspeptic  diarrhoea) . 

Prognosis. — Most  cases  of  nervous  diarrhoea  give  a  favor- 
able prognosis.  In  some  instances  the  diarrhoea,  origi- 
nally of  a  nervous  origin,  assumes  a  chronic  course  and 
ultimately  produces  an  enteritis. 

Treatment. — The  treatment  will  vary  according  to  the 
type  of  the  diarrhoea.  In  nervous  diarrhoea  proper  the 
general  condition  of  the  patient  must  be  strengthened  and 
the  remedies  will  have  to  be  directed  toward  this  end. 
Arsenic  and  iron  will  often  prove  eflScient.  In  some  cases 
the  administration  of  bromides  for  a  few  weeks  will  be  of 
great  benefit. 

In  nervous  diarrhoea  dependent  on  a  reflex  action  emanat- 
ing from  some  other  diseased  organ,  the  treatment  must 
be  directed  toward  the  primary-  affection. 

In  all  cases  of  nervous  diarrhoea,  persistent  training  of  the 

intestines  in  the  normal  direction  must  be  urged  by  the 

physician.     The  imtieut  should  be  instructed  after  having 

had  his  first  movement  in  the  morning  to  refrain  from  any 

other  evacuations  of  the  bowels  during  this  day,  answering 

nature's  call  only  when  absolutely  necessary.     In  quite  a 

number  of  instances  the  patient  at  first  continues  to  have 
19 


290  DISEASES  OP  THE  INTESTINES. 

the  desire  for  an  evacuation  quite  often,  but  succeeds  in 
controlling  it.  Later  on  the  desire  for  defecation  appears 
less  often  and  at  last  a  normal  state  is  reached. 

In  dyspeptic  diarrhoea  the  treatment  should  be  directed 
toward  the  improvement  of  the  abnormal  condition  of  the 
stomach.  Thus  diarrhoea  due  to  hyperchlorhydria  can  be 
successfully  checked  by  bicarbonate  of  sodium  taken  in  half- 
teaspoonful  or  teaspoonful  doses  two  hours  after  meals. 
The  diarrhoea  resulting  from  achylia  gastrica  can  be  rem- 
edied bj'  a  diet  rich  in  vegetable  foods,  prepared  in  such 
a  manner  that  they  are  easily  broken  up  into  minute  par- 
ticles. Stomachics,  intragastric  faradization,  and  gener- 
ally the  treatment  of  achylia  gastrica  will  also  control  the 
diarrhoea. 

In  stercoral  diarrhoea  an  efficient  cathartic  is  the  best 
means  of  checking  the  diarrhoea.  Diarrhoea  having  its 
cause  in  a  faulty  composition  of  the  blood  should  be  rem- 
edied by  improving  the  constitutional  condition.  If  this 
is  impossible  the  treatment  must  be  symptomatic. 

In  this  connection  it  may  be  advisable  to  describe  the 
means  we  have  at  our  command  symptomatically  to  treat 
diarrhoea,  no  matter  of  what  nature  it  may  be.  The  first 
l^lace  must  be  given  to  oi)ium,  a  remedy  which  has  stood 
the  test  of  ages  and  is  still  the  most  reliable.  It  efficientlj- 
decreases  the  abnormal  i)eristalsis  and  probably  also  di- 
minishes the  intestinal  secretion.  Morphine  and  the  other 
derivatives  of  opium  act  in  a  similar  manner,  but  opium  as 
such  seems  to  be  preferable  in  diarrhoea!  conditions.  Be- 
sides opium  there  is  hardly  another  remedy  efficiently  to 
check  increased  intestinal  peristalsis,  although  there  are 
several  others  which  may  arrest  the  diarrhoea.  Among 
these  may  be  mentioned  nitrate  of  silver,  subnitrate  and 
salicylate  of  bismuth,  and  all  the  remedies  containing  tan- 


CONSTIPATION.  291 

nic  acid.  Another  important  means  in  treating  diarrhoeal 
conditions  is  heat.  A  hot-water  bag  or  warm  linseed  poul- 
tice applied  over  the  abdomen  and  warm  drinks  have  a 
favorable  influence  upon  the  diarrhoea. 

Constipation. 

Sijnonyms. — Habitual  constipation,  atony  of  the  bowel, 
constipatio,  constipatio  alvi,  obstipatio. 

Definition. — By  constipation  is  understood  a  diminution 
in  the  frequency  of  evacuations  of  the  bowels. 

General  Remarks. — Healthy  persons  have  as  a  rule  one 
evacuation  of  the  bowels  daily.  Under  normal  conditions 
a  movement  occurs  almost  always  at  about  the  same  time 
of  the  day.  The  cause  of  this  periodicity  lies  most  prob- 
ably in  nervous  influences.  As  mentioned  above  in  the 
chapter  on  physiology,  the  contents  of  the  small  intestine 
are  propelled  with  comparative  rapidity.  In  the  large  in- 
testine, however,  the  prochoresis  is  very  slow.  The  upper 
rectum  and  the  sigmoid  flexure  form  a  reservoir  for  the 
storage  of  the  fecal  matter.  Once  in  twenty-four  hours 
through  certain  nervous  influences  the  faeces  are  carried 
lower  down  into  the  ampulla  of  the  rectum  and  there  is 
then  experienced  the  desire  for  defecation.  This  is  accom- 
plished voluntarily  by  relaxing  the  sphincter  ani  and  by 
exercising  a  moderate  pressure  with  the  abdominal  walls 
after  more  or  less  deep  inspirations.  No  pain  is  connected 
with  this  act  and  a  rather  pleasant  sensation  is  felt  after 
its  accomplishment. 

Even  physiologically  there  is  a  great  variability  in  the 
number  of  movements.  Some  persons  have  normally  two 
or  three  movements  a  day  all  their  lifetime,  while  others 
have  only  one  evacuation  every  other  day  or  even  every 
three  days.     In  both  instances  there  may  be  no  abnormal 


292  DISEASES  OF  THE  INTESTINES. 

sensations  whatever  and  we  are  thus  forced  to  consider 
them  as  physiological.  Constipation,  therefore,  should 
signify  a  condition  in  which  a  person  has  less  frequent 
movements  than  he  has  been  accustomed  to. 

In  rare  instances,  however,  the  number  of  evacuations 
remains  the  same,  but  their  quantity  diminishes.  Thus  a 
stagnation  of  fecal  matter  in  the  bowels  occurs  (copros- 
tasis).  This  condition  is  also  usually  comprised  under 
the  head  of  constipation.  The  quantity  of  the  daily 
evacuation  of  the  bowel  varies  greatly,  depending  princi- 
pally upon  the  diet.  A  vegetable  diet  gives  voluminous 
stools,  while  one  consisting  mainly  of  meats  produces  only 
a  small  quantity  of  fecal  matter.  The  average  quantity 
of  fecal  matter  for  twenty-four  hours  is  about  250  c.c. 
While  a  marked  divergence  from  the  above-mentioned  fig- 
ure must  be  recognized  as  pathological,  a  small  decrease 
of  evacuated  fecal  matter  cannot  be  easily  discovered,  the 
more  so  since,  according  to  Woodward,  a  considerable 
quantity  of  the  fecal  matter  is  made  up  of  micro-organ- 
isms whose  number  is  apt  to  vary  greatly,  even  under 
normal  conditions. 

Constipation  may  be  due  to  organic  lesions  of  the  bowel 
(stenosis  of  the  intestine  or  catarrhal  conditions),  or  may 
exist  without  apparent  anatomical  changes  in  the  intestinal 
tract,  and  thus  be  functional  in  nature.  The  latter  class 
alone  is  dealt  with  here,  Inasmuch  as  in  the  great  major- 
ity of  these  cases  of  constipation  a  disturbance  in  the  ner- 
vous apparatus  of  the  intestine  may  be  presumed  to  exist, 
we  discuss  constipation  in  this  chapter  on  intestinal  neu- 
roses. 

Etiology. — Habitual  constipation  may  be  divided  into 
three  groups:  1.  Constipatiou  due  to  retarded  intestinal 
peristalsis  (atony  of  the  bowel).     2.  Constipation  due  to 


CONSTIPATION.  293 

a  spasmodic  contraction  of  a  certain  portion  of  intestine 
(enterospasmus,  spastic  constipation).  3.  Constipation 
depending  upon  abnormal  conditions  of  other  organs. 

With  regard  to  the  etiology-  of  the  first  group,  namely, 
constipation  due  to  atony  of  the  bowels,  which  comprises 
by  far  the  greater  majority  of  cases,  the  following  may  be 
said :  In  most  instances  the  constipation  is  brought  on  by 
a  repeated  neglect  of  nature's  calls.  Thus,  young  girls 
while  in  school  suppress  the  desire  for  defecation  out  of 
bashfulness,  which  gives  rise  at  first  to  irregularity  of  the 
bowels  and  later  on  to  constipation.  The  mental  state  is 
also  responsible  to  a  great  extent  for  the  causation  of  this 
trouble. 

It  is  not  among  the  working  class  that  constipation  is 
most  frequently  found,  but  among  the  wealthier  classes. 
This  shows  that  the  mode  of  living  has  much  to  do  with 
this  affection.  If  we  would  go  a  little  more  into  detail 
and  try  to  analyze  cases  of  chronic  constipation,  we  would 
learn  that  the  patient  had  perhaps  at  first  a  great  deal  of 
worry  or  of  mental  strain.  At  that  time  his  bowels  first 
became  sluggish  and  aft^r  a  while  the  affection  became 
more  develojjed.  The  patient  experienced  more  and  more 
difficulty,  began  to  take  drugs,  and  after  a  short  time  was 
not  able  to  have  a  movement  without  medicine. 

Often  we  find  that  after  an  acute  gastric  catarrh  there 
was  at  first  a  little  diarrhoea,  which  after  a  few  days 
changed  into  constipation.  After  a  short  time  this  would 
have  disappeared  of  itself,  if  the  patient  in  his  haste  to  have 
a  movement  had  not  resorted  to  cathartics,  thus  upsetting 
again  the  normal  state  of  the  intestinal  tract,  in  conse- 
quence of  which  chronic  constipation  developed.  Very 
frequently  the  patient  has  some  trouble,  perhaps  a  head- 
ache, and  thinks  the  stomach  is  disordered,   and  begins 


294  DISEASES  OF  THE  INTESTINES. 

to  live  on  a  one-sided  diet,  avoids  vegetables,  butter,  fat 
— all  substances  which  excite  the  peristaltic  action  of  the 
bowels — and  then  constipation  arises  and  assumes  a  chronic 
form. 

In  a  limited  number  of  cases  the  retarded  intestinal 
peristalsis  is  due  to  a  real  muscular  weakness  of  the 
bowel,  the  intestinal  muscularis  being  much  thinner 
than  normally.  Nothnagel  observed  some  cases  in  which 
at  the  autopsy  the  muscularis  of  the  large  bowel  measured 
in  thickness  0.12  to  0.25  mm.,  while  normally  it  ought 
to  be  0.5  to  1  mm.  In  these  cases  the  muscular  devel- 
opment of  the  entire  body  was  poor.  It  will  therefore  be 
easily  seen  that  such  rare  conditions  cannot  be  recognized 
during  life. 

In  former  years  the  opinion  prevailed  that  chronic  consti- 
pation gives  rise  to  the  developement  of  numerous  nervous 
affections  (neurasthenia,  hypochondriasis,  hysteria,  and 
even  epilepsy  and  paranoia).  Dunin  '  was  the  first  to  show 
that  in  reality  quite  the  reverse  is  true,  namely,  that  con- 
stipation is  the  result  of  many  nervous  conditions  and  not 
their  origin,  for  a  treatment  directed  against  the  existing 
neurosis  in  many  instances  removes  the  constipation  with- 
out the  administration  of  cathartics.  Dunin,  however, 
goes  too  far  in  ascribing  all  cases  of  habitual  constipation 
to  a  neurosis.  There  are  certainly  cases  of  chronic  consti- 
pation in  which  no  nervous  derangement  whatever  can  be 
discovered. 

Formerly  the  cause  of  constipation  was  presumed  to  lie 
in  abnormal  conditions  of  the  bowels.  Thus,  peritonitic 
adhesions  of  the  intestines  and  congenital  malposition  of 
the  bowel  have  been  held  responsible  for  chronic  consti- 

'  Dunin  r  "  Ueber  habituelle  Stuhlverstopfung,  deren  Ursachen  und 
Behandlung.  "    Berliner  Klinik,  1891,  Heft  34. 


CONSTIPATION.  296 

pation.  But  aside  from  the  fact  that  these  two  factors 
are  so  rarely  found  in  comparison  with  the  large  num- 
ber of  cases  of  constipation,  Leichtensteru '  proved  that 
an  abnormal  position  of  the  bowels  need  not  cause  con- 
stipation as  long  as  the  intestinal  lumen  is  not  obstructed. 

Spasmodiq  contraction  of  the  bowels  or  enterospasinviB 
is  produced  by  increased  peristaltic  action  confined  to  one 
portion  of  the  bowels.  A  permanent  contraction  of  a  por- 
tion of  the  intestine  exists  which  may  affect  both  the  circu- 
latory and  the  longitudinal  muscles.  This  spastic  state 
may  be  of  variable  duration  and  may  involve  intestinal 
segments  of  different  lengths.  The  contracted  portion  of 
the  bowel  is  almost  completely  occluded,  thus  creating 
an  obstacle  to  the  onward  passage  of  the  intestinal  con- 
tents. 

The  enterospasm  may  involve  the  entire  small  intes- 
tine. The  abdomen  then  appears  contracted  in  the  form 
of  a  trough.  This  condition  is  met  with  in  spinal  menin- 
gitis and  in  other  morbid  processes  involving  the  pons 
and  the  medulla  oblongata.  Moreover,  the  same  affection 
occurs  in  chronic  lead  poisoning. 

Much  more  frequent  than  the  diffused  enterospasm  is 
the  localized  or  circumscribed  contraction  of  the  bowel 
which  usually  affects  a  certain  portion  of  the  large  intes- 
tine. Here  the  abdomen  does  not  show  any  abnormal 
appearance  on  inspection.  This  condition  is  frequently 
met  with  in  nervous  people,  neurasthenics,  hysterical  per- 
sons, and  also  in  those  debilitated  by  long  ailments.  Con- 
stipation of  an  obstinate  nature,  lasting  for  several  days, 
followed  by  a  painful  evacuation  of  small  balls  (like  the 

'  Leichtenstem  :  "  Verengerungen,  Verschliessungen  und  Lageveran- 
derungen  des  Darms."  von  Ziemssen's  "Handbuch  der  speciellen  Pa- 
thologic und  Therapie,  "  Bd.  vii.,  2te  Halfte.  Leipzig,  1878. 


296  DISEASES  OP  THE  INTESTINES. 

faeces  of  goats)  or  leadpencil-shaped  fecal  matter  are  the 
predominant  symptoms.  Pains  in  the  umbilical  region  or 
on  the  left  side  of  the  lower  abdomen  of  a  constricting 
nature  and  relieved  after  a  very  small  passage,  are  also 
characteristic  of  this  affection. 

Constipation  Depending  upon  Diseases  of  Other  Organs. 
Numerous  diseases  of  the  stomach  give  rise  to  constipa- 
tion. Foremost  among  these  are  hyperchlorhydria,  ulcer 
and  cancer  of  the  stomach,  ischochymia,  atonic  and  catar- 
rhal conditions  of  the  stomach,  and  finally  achylia  gastrica 
— the  last  three,  however,  show-  a  smaller  percentage  of 
this  complication.  In  this  group  of  cases  constipation  is 
attributable  either  to  the  abnormal  qualities  of  the  chyme 
passing  through  the  digestive  canal  or  to  the  retarded  gas- 
tric prochoresis  or  to  some  retarding  reflex  act  originating 
in  the  stomach. 

Tumors  of  the  intestinal  canal  or  of  neighboring  organs 
compressing  the  bowel,  strictures  within  the  intestines,  and 
peritonitic  adhesions  are  also  often  associated  with  consti- 
pation. These  conditions,  moreover,  frequently  lead  to  a 
far  more  serious  condition,  namely,  to  acute  or  chronic 
ileus.  Catarrhal  inflammation  of  the  small  intestines  alone 
is  also  ordinarily  accompanied  by  constipation.  Ulcers 
of  the  small  intestine  are  sometimes  attended  by  constipa- 
tion. Ulcers  'of  the  large  bowel  are  ordinarily  accompa- 
nied by  diarrhoea,  excepting  dysenteric  ulcers,  which  often 
produce  constipation.  Fissure  of  the  anus  and  an  increased 
contraction  of  the  sphincter  of  the  anus  are  often  causes  of 
constipation. 

In  many  diseases  of  the  brain,  spinal  cord,  and  the 
nerves  (cerebro-spinal  meningitis,  brain  tumors,  hemor- 
rhages of  the  brain,  chronic  hydrocephalus,  myelitis, 
tabes,  neuroses  and  psychoses)  constipation  is  present. 


CONSTIPATION.  297 

It  is  due  here  either  to  a  disturbance  of  the  nervous  appa- 
ratus communicating  with  the  centre  for  defecation,  or  to 
a  diminished  sensibility  of  the  intestinal  nerves  so  that 
stronger  stimuli  are  required  than  under  normal  condi- 
tions. 

Diseases  of  the  lungs,  heart,  liver,  and  kidney  increase 
the  liability  to  constipation,  first,  by  the  hyperemia  of 
the  intestinal  mucosa,  and,  secondly,  by  the  congestion 
in  the  portal  circulation,  which  both  retard  the  peristalsis' 
Diabetes  mellitus  often  gives  rise  to  constipation,  first, 
by  the  polyuria  which  drains  the  organism  of  water  and 
thus  leads  to  an  exsiccated  condition  of  the  fecal  matter, 
and,  secondly,  by  the  diet,  which  consists  principally  of 
meat  and  of  a  very  restricted  quantity  of  starchy  food. 
Diarrhoea,  however,  is  not  rarely  met  with  in  this  disease. 

Ansemia  and  chlorosis  are  also  often  attended  by  consti- 
pation. The  latter  is  due  to  an  atonic  condition  of  the 
bowels,  which  is  one  of  the  symptoms  of  the  general  mus- 
cular atony  dependent  upon  the  impoverishment  of  the 
blood. 

Most  febrile  diseases  are  also  usually  accompanied  by 
constipation.  Lack  of  exercise  and  an  increased  elimina- 
tion of  the  fluids  of  the  body  caused  by  the  greater  activity 
of  the  lungs  and  the  sudoriparous  apparatus  are  the  prin- 
cipal factors.  Constipation  encountered  in  people  living 
in  high  altitudes  must  be  ascribed,  according  to  Euedi,' 
to  the  same  causes.  The  restricted  diet,  consisting  chiefly 
of  milk,  also  contributes  to  a  lessened  activity  of  the  intes- 
tinal peristalsis. 

Symptomatolo(jy.—ln  many  cases  constipation  does  not 
induce  any   subjective  symptoms  whatever.     Ordinarily, 

'  Carl  Ruedi .  "  On  Indications  and  Contraindications  of  High  Alti- 
tude in  Phthisis."    The  Climatologist,  July,  1892. 


298  DISEASES  OP  THE  INTESTINES. 

however,  continued  constipation  gives  rise  to  sensations 
of  slight  pressure,  fulness  and  tension  in  the  abdomen; 
and  borborygmi  may  at  times  molest  the  patient.  Occa- 
sionally intense  colicky  pains  are  experienced.  These  are 
due  to  an  increased  effort  of  the  intestines  to  rid  them- 
selves of  the  accumulated  fecal  matter  by  violent  contrac- 
tions. The  abdomen  is  often  symmetrically  distended, 
rarely  asymmetrically,  namely,  in  partial  atony  of  the 
bowels. 

In  patients  with  thin  abdominal  walls,  a  more  or  less 
filled  state  of  some  portions  of  the  intestine,  especially 
of  the  colon,  may  be  i)erceived  by  inspection  and  pal- 
pation. The  appetite  is  often  diminished  and  in  some 
instances  complete  anorexia  exists.  Other  gastric  symp- 
toms— belching,  nausea,  pyrosis,  feeling  of  i^ressure  after 
meals,  and  bad  taste  in  the  mouth — may  be  present.  That 
all  these  symptoms  are  due  to  the  constipation  and  not  to 
a  separate  lesion  in  the  stomach,  is  proven  h\  the  fact  that 
thoy  all  disappear  as  soon  as  efficient  evacuation  of  the 
bowels  has  taken  place. 

Besides  these  gastric  symptoms  the  following  derange- 
ments may  be  present :  congestion  of  the  head,  dizziness, 
headaches,  sleeplessness,  a  despondent  feeling,  palpitation 
of  the  heart,  tachycardia,  in'egularity  of  the  pulse.  The 
latter  symptoms  have  been  considered  by  many  writers  to 
be  due  to  auto-intoxication  from  the  intestinal  tra^t.  Ac- 
cording to  the  experiments  of  Bouchard,'  however,  this 
does  not  seem  to  be  true,  for  this  investigator  has  shown 
that  intoxication  within  the  intestinal  tract  takes  place 
when  there  is  a  retention  of  fluid  fecal  matter,  but  not 
when  the  fseces  are  solid,  for  in  this  condition  no  absorp- 
tion of  the  fecal  matter  takes  place. 

>  Bouchard  :  Loc.  cit 


CONSTIPATION.  299 

Constipation  which  has  lasted  for  a  long  time,  as  a  rule, 
terminates  by  a  spontaneous  evacuation  of  ordinarily  very 
hard  masses  of  fecal  matter.  The  latter  often  appears  in 
the  form  of  balls  which  may  be  covered  with  a  thin  layer 
of  mucus.  In  some  instances  the  constipation  terminates 
in  an  attack  of  diarrhoea.  In  these  cases  the  diarrhoea  has 
been  caused  by  an  acute  hyperaemia  and  inflammation  of 
the  intestinal  mucosa  due  to  the  hardened  fecal  matter,  the 
latter  becoming  liquefied  through  increased  intestinal  per- 
istalsis and  secretion.  In  other  instances  no  spontaneous 
evacuation  takes  place  and  it  becomes  necessary  to  make 
use  of  different  cathartic  remedies  in  order  to  i)roduce  a 
movement  of  the  bowels. 

Retention  of  fecal  matter  may  cause  not  only  a  slight 
transient  catarrhal  condition  of  the  bowels  as  just  referred 
to,  but  may,  although  rarely,  effect  more  pronounced  an- 
atomical lesions,  as  formation  of  ulcers  (stercoral  ulcers), 
local  peritonitis,  and  even  perforation  of  the  gut  with  fatal 
issue. 

One  of  the  serious  symptoms  which  may  result  from 
continued  constipation  is  fecal  colic.  The  latter  begins 
with  sudden  violent  pain  of  a  colicky  nature  in  the  al> 
domen.  In  weakened  persons  fainting  spells  may  occur. 
The  abdomen  is  usualh'  greatly  bloated  and  tender  on 
pressure.  Passing  of  wind  (flatus)  gives  temporary  relief, 
but.  the  pains  soon  reappear  and  subside  only  after  an 
efficient  evacuation.  Fecal  colic  is  mostly  observed  in 
cases  of  obstinate  constipation,  although  it  may  occur  in 
patients  with  daily  evacuations  of  the  bowels,  but  in  these 
insufficient  fecal  passages  must  be  presupposed.  In  fact, 
hardened  balls  of  fecal  matter  can  be  discovered  in  such 
cases  on  palpation  of  the  alxlomeu. 

These  conditions  are  not  always  of  a   mild  character. 


300  DISEASES  OF  THE  INTESTINES. 

As  a  rule  cathartic  remedies  are  efficient.  In  some  cases, 
however,  the  latter  produce  energetic  intestinal  peristalsis 
and  violent  pains,  but  fail  to  secure  a  copious  movement. 
Under  these  circumstances  the  patient  may  after  a  while 
sink  into  a  state  of  collapse  and  be  seized  with  a  paroxysm 
of  vomiting.  The  clinical  picture  now  resembles  very 
closely  that  of  ileus.  High  rectal  irrigations  or  injections 
of  oil  into  the  bowel  ordinarily  yet  produce  the  desired 
effect  and  the  patient  quickly  recuperates.  In  rare  cases, 
however,  especially  in  very  old  and  cachectic  persons,  these 
means  also  remain  fruitless.  Total  paralysis  of  the  intes- 
tine now  takes  place  and  the  patients  are  then  in  a  most 
critical  condition. 

A  frequent  complication  of  constipation  is  the  formation 
of  fecal  tumors.  They  are  found  most  frequently  in  the 
cjecum,  rectum,  and  at  the  colic  flexures.  These  masses 
may  cause  a  dislocation  of  the  colon ;  thus,  such  a  tumor 
may  be  felt  just  above  the  symphysis  and  may  belong  to 
the  transverse  colon  which  has  been  dragged  down  to  that 
region.  Fecal  tumors  are  as  a  rule  easily  recognizable. 
They  are  not  of  a  very  firm  consistency,  have  a  rosary-like 
configuration,  are  movable,  and  undergo  a  change  in  shape 
upon  pressure.  They  may  be  of  large  size.  Thus  Levi ' 
found  the  rectal  pouch  of  a  patient  suffering  for  nine  years 
with  constipation  filled  witn  a  fecal  mass  weighing  four 
pounds.  Still  larger  fecal  concretions  have  been  found 
by  Lemazurier."  These  large  masses  necessarily  dilate 
the  colon. 

Habershon  described  cases  in  which  the  dilated  colon 
measured  twelve  to  fifteen  inches  in  circumference,  and 
atated  that  some  of  the  normal  sacculations  of  the  colon 

'  Levi :  Gazette  med.,  1839. 

*  Lemazurier  :  Arch.  gen.  de  med.,  vol.  i. 


CONSTIPATION.  301 

may  become  distended  to  such  a  degree  that  they  appear 
as  true  diverticula.  In  the  latter  fecal  accumulations  may 
occur  which  remain  undisturbed  by  the  further  passage  of 
the  intestinal  contents.  These  stagnant  fecal  masses  often 
produce  inflammatory  processes  which  may  lead  to  a  de- 
struction of  the  intestinal  coats  down  to  the  peritoneum 
The  colon  occasionally  is  distended  not  only  in  width 
but  also  in  length.  The  latter  circumstance  explains  the 
abnormal  position  of  the  bowel  often  present  in  these 
cases. 

Among  the  local  symptoms  which  constipation  produces 
hemorrhoids  play  an  important  part.  They  are  treated 
in  a  special  chapter. 

A  host  of  nenous  symptoms  may  develop  in  consequence 
of  constipation  in  i:)eople  who  are  apparently  not  nervously 
inclined.  Thus  constijiation  lasting  several  days  may 
produce  slight  cerebral  symptoms,  namely,  a  sensation  of 
pressure,  weight  and  dulness  in  the  head,  sometimes 
headaches  and  vertigo.  The  dependence  of  these  symp- 
toms upon  constipation  is  proved  by  the  fact  that  after  a 
full  evacuation  of  the  bowels  they  all  suddenly  disappear, 
but  again  return  after  another  period  of  constipation.  We 
have  as  yet  no  positive  explanation  of  the  causation  of 
these  symptoms.  Some  authors  assume  them  to  be  of  a 
reflex  origin. 

Leube '  described  several  cases  of  intestinal  vertigo  in 
which  the  dizziness  was  due  to  pressure  existing  in  the  lower 
end  of  the  bowels,  the  vertigo  appearing  only  in  consequence 
of  irritation  of  the  intestinal  walls  by  fecal  matter  or  a  large 
amojiut  of  gas,  or  by  the  examining  finger.  Leube  concluded 
that  pressure  upon  the  hemorrhoidal  j^lexuses  of  the  sym- 

'  Leube  :  "  Ueber  Darmschwindel.  "  Deutsches  Arch.  f.  klin.  Medi- 
cin.  Bd.  36,  1885. 


302  DISEASES  OP  THE  INTESTINES. 

pathetic  nerve  produces  the  sensation  of  vertigo  in  are- 
flex  way. 

Senator'  tried  to  explain  the  above  symptoms  as  due 
to  the  absorption  of  poisonous  gases  within  the  intestine, 
such  as  sulphuretted  hydrogen,  and  Nothnagel  assumed 
that  ptomains  may  be  absorbed  and  thus  cause  an  auto- 
intoxication. But  neither  theory  seems  to  hold  good ;  for 
sulphuretted  hydrogen  gas  exists  in  too  small  quantities 
to  produce  any  marked  symptoms,  and  the  fecal  ptomains 
can  scarcely  be  absorbed  from  dried-up  fecal  matter. 

As  mentioned  above,  real  brain  diseases,  hypochondria 
and  melancholia,  are  never  due  to  constipation  as  such. 
There  is,  however,  hardly  any  doubt  that  in  nervously 
inclined  individuals  obstinate  constipation  may  be  a  con- 
tributing factor  in  the  further  development  of  some  psy- 
choses, especially  melancholia. 

Fecal  fever,  which  has  played  a  great  part  in  the  works 
of  old  writers,  appears  to  be  due  in  most  instances  not  to 
an  accumulation  of  fecal  matter  but  rather  to  some  com- 
plicating condition,  an  inflammatory  process,  a  stercoral 
ulcer,  a  local  peritonitis,  etc.  In  infants  and  children, 
however,  who  much  more  readily  develop  fever,  the  latter 
may  be  due  to  accumulation  of  fecal  matter  alone.  Some 
of  the  English  writers  have  referred  to  chlorosis  as  due  to 
habitual  constipation,  and  Clark  has  treated  chlorosis  with 
cathartics.  But  this  view  has  not  been  generally  accepted 
and  the  dependence  of  chlorosis  upon  constipation  is  far 
from  being  proved. 

Diagnosis. — The  recognition  of  constipation  is  not  diffi- 
cult, except  in  those  cases  in  which  there  is  a  daily  evacu- 
ation of  the  bowels  but  not  a  complete  one,  so  that  fecal 

'Senator:  " Hydrothionaemie  und  Selbstinfection  durcb  abnorme 
Verdauungsvorgange.  "    Berl.  klia.  Wochenschr. ,  1868,  No.  24. 


CONSTIPATION.  303 

matter  is  more  and  more  accumulated  in  the  intestine. 
Frequently  hard  fecal  masses  of  rosary  shape  will  be  dis- 
covered on  palpation  of  the  abdomen  in  the  region  of  the 
colon.  Most  often  the  sigmoid  flexure  and  the  caput  coli 
are  the  favored  sites  of  this  phenomenon.  The  detection 
of  these  fecal  masses  shows  the  existence  of  an  insufficient, 
evacuation  of  stools,  in  other  words,  constipation. 

The  diagnosis  of  pure  constipation  (habitual  constipa- 
tion) can  be  made,  if  organic  lesions  of  the  bowels  (stric- 
ture, tumor,  and  also  intestinal  catarrh)  can  be  excluded. 
Tliis  diagnosis  having  been  made,  it  is  of  importance  to 
find  out  to  which  group  the  constipation  belongs,  whether 
it  be  due  to  an  abnormal  gastric  condition,  or  disease  of 
some  other  organ,  or  to  a  neurotic  affection  of  the  bowel 
itself  (atonic  and  spastic  constipation). 

Constipation  due  to  anomalies  of  the  function  of  the 
stomach  can  be  ascertained  only  after  a  thorough  analysis 
of  the  gastric  contents  and  after  resort  to  treatment  directed 
toward  the  improvement  of  the  gastric  condition.  Con- 
stipation due  to  disease  of  other  organs  (heart,  lungs, 
kidneys,  liver,  etc.)  may  be  assumed  to  exist  when  an 
examination  discloses  their  presence.  Constipation  due 
to  atony  of  the  bowels  is  often  revealed  by  a  slightly 
bloated  condition  of  the  abdomen  with  evacuations  of  hard 
fecal  matter,  often  balls,  sometimes  covered  with  a  thin 
layer  of  mucus.  While  there  may  be  a  feeling  of  despond- 
ency, dizziness,  and  somnolence,  real  severe  pains  are 
rare.  Constipation  due  to  a  spasmodic  contraction  of  the 
bowel  is  attended  with  a  general  feeling  of  uneasiness  and 
pains  in  the  abdomen,  occasionally  accompanied  by  fainting 
fits.  The  fecal  matter  is  not  so  hard,  although  it  is  evac- 
uated only  after  severe  straining  of  the  abdominal  walls, 
and  is  voided   in  narrow  tapelike  pieces.     The  abdomen 


304  DISEASES  OF  THE  INTESTINES. 

is  often  rather  sunken  and  contracted.     Intestinal  coils  can 
frequently  be  f)alpated. 

Prognosis. — The  prognosis  of  constipation  is  favorable  in 
the  large  majority  of  cases,  especially  with  regard  to  life. 
It  must,  however,  be  admitted  that  after  having  lasted  a 
long  time  constipation  may  give  rise  to  severe,  sometimes 
irreparable  anatomical  lesions  of  the  intestine,  as  for  in- 
stance atrophy,  peritonitic  adhesions,  malpositions  of  the 
bowel,  evfen  perforation  with  consequent  peritonitis  and 
death.  The  latter  instances,  however,  are  very  rare,  if  we 
take  into  consideration  the  large  number  of  persons  suffer- 
ing with  constipation  who  reach  an  advanced  age,  and  they 
will  most  probably  become  still  less  frequent  if  the  patients 
do  not  neglect  this  condition  and  consult  a  physician  at  an 
early  period. 

Treatment. — Cases  of  constipation  due  to  dyspeptic  con- 
ditions must  be  treated  by  first  ameliorating  the  gastric 
disorder.  Cases  of  constipation  secondary  to  diseases  of 
other  organs  must  be  managed  by  first  applying  remedies 
toward  the  improvement  of  the  original  trouble.  If  these 
alone  are  insufficient,  they  must  be  managed  like  typical 
cases  of  habitual  constipation. 

With  regard  to  the  prophylaxis  of  constipation,  we 
should  avoid  administering  cathartics  in  slight  transient 
disturbances  of  digestion  and  rather  let  nature  take  its  own 
course.  Never  put  a  patient  on  a  one-sided  diet  for  too 
long  a  time ;  the  exclusion  of  vegetables,  fruits,  and  starchy 
foods  in  general,  from  the  diet  is  frequently  the  cause  of 
marked  constipation.  A  hygienic  mode  of  living,  regular 
habits,  less  business  strain  and  worry,  and  more  outdoor 
life  and  exercise  are  of  the  greatest  importance  in  the  pre- 
vention of  constipation. 

Generally  no  purgatives  whatever,  or  as  few  as  possible, 


CONSTIPATION.  305 

should  be  used.     The  chief  measures  in  curing  constipa- 
tion are  the  following : 

1.  The  Moral  Treatment. — It  is  of  utmost  importance  to 
allay  the  patient's  anxietj'  to  have  a  movement.  He  should 
be  told  to  pay  as  little  attention  as  possible  to  the  condi- 
tion of  his  bowels.  Absence  of  a  movement  for  a  few  days 
will  cause  no  harm  whatever.  Avoidance  of  purgatives  and 
keeping  the  mind  of  the  patient  free  from  worry  over  tbe 
condition  of  his  bowels  is  occasionally  sufficient  to  produce 
spontaneous  movements. 

Training  the  patient  to  have  an  evacuation  at  a  certain 
time  every  day  is  also  of  great  importance.  The  patient 
should  be  taught  to  go  to  the  watercloset  every  morning  at 
the  same  time  and  should  try  to  have  a  passage.  In  doing 
this  he  should  not  exert  himself  too  hard  and  should  spend 
only  three  to  five  minutes  for  this  purpose.  In  case  the 
attempt  be  unsuccessful,  he  should  wait  until  the  follow- 
ing morning,  unless  there  is  a  strong  desire  to  go  to  stool. 
Trousseau  was  the  first  to  advocate  this  mode  of  treatment, 
and  the  importance  of  this  maxim  has  since  been  gen- 
erally accepted.  My  own  experience  coincides  with  that  of 
others,  and  I  cannot  lay  too  much  stress  upon  this  ap- 
parently unimportant  piece  of  advice.  Even  when  using 
other  measures  in  combating  constipation  we  must  not 
lose  sight  of  the  influence  in  "  training  "  the  patient. 

2.  Dietetic  Measures.— The  dietetic  measures  have  for 
their  object  the  ingestion  of  foods  which  increase  the  intes- 
tinal peristalsis  and  the  avoidance  of  substances  which  are 
of  a  more  or  less  constipating  nature.  Advocate  the  drink- 
ing of  plain  cold  water,  especially  in  the  fasting  condition, 
the  use  of  buttermilk,  cider,  grapes,  oranges,  and  other 
fruits,  raw  or  cooked  (aj^ples,  prunes,  pears,  peaches), 
lemonade,   honey;    salmon,  sardines,   herring,   plenty  of 

20 


306  DISEASES  OF  THE  INTESTINES. 

vegetables,  spinach,  green  peas,  cauliflower,  cabbage,  green 
salads,  rye  bread,  butter.  Avoid  strong  tea,  claret,  huckle- 
berries, cacao  and  chocolate. 

Some  substances  have  a  constipating  effect  upon  one 
person  and  a  purgative  effect  upon  another,  as  for  instance 
milk.  In  treating  the  patient  we  must  acquaint  ourselves 
with  his  peculiarities  in  this  respect.  In  prescribing  a 
diet  for  patients  with  constipation  we  should  allow  them 
the  usual  foods  with  a  predominance  of  those  just  enum- 
erated. It  is  needless  to  say  that  some  of  the  articles 
mentioned  will  not  be  permissible  in  every  case.  Thus  a 
patient  with  a  very  delicate  stomach  should  certainly  be 
told  not  to  take  cabbage  and  cider,  etc. 

Ih  some  instances  in  which  too  much  vegetable  food  has 
been  taken  and  a  constipation  has  developed  in  consequence 
of  the  intestine  being  overburdened  with  too  much  ballast, 
food  articles  containing  much  cellulose  will  have  to  be  re- 
stricted. As  a  rule,  however,  a  mixed  diet  with  a  prepon- 
derance of  vegetable  food  is  adapted  for  most  cases. 

3.  3Iecha)iical  Measures. — The  mechanical  measures 
serve  to  strengthen  the  bowel  and  in  this  way  promote  a 
better  action,  or  they  directly  effect  a  stronger  intestinal 
peristalsis.  The  mechanical  measures  comprise  massage, 
exercise,  electricity,  hydrotherapy,  and  lastly  injections 
into  the  bowel. 

(a)  Massage.  The  general  principles  of  massage  have 
been  described  above  (page  80).  Its  action  consists  prin- 
cipally in  producing  more  efficient  peristalsis  of  the  large 
bowel.  It  should  therefore  never  be  used  in  conditions  in 
which  spasmodic  contractions  of  the  bowel  may  be  assumed 
to  exist.  Its  most  useful  field  lies  in  cases  of  atony  of  the 
bowel. 

Massage  should  be  applied  at  first  either  by  the  physi- 


CONSTIPATION.  307 

cian  himself  or  under  his  strict  supervision.  It  should 
never  be  applied  with  much  force  and  it  should  never 
cause  pain.  According  to  Illoway , '  the  duration  of  massage 
treatment  should  be  from  five  to  fifteen  minutes  for  a 
grown  person  and  from  three  to  five  minutes  for  children. 
The  massage  should  be  employed  every  other  day  with 
great  regularity  for  a  period  of  about  six  weeks  at  least. 
Illoway  suggests  that  the  massage  sittings  may  be  per- 
formed less  frequently  as  soon  as  there  is  a  decided 
improvement  in  the  condition  of  the  bowels.  It  is,  how- 
ever, never  advisable  to  stop  the  massage  treatment  sud- 
denly, but  it  should  rather  be  kept  up  for  a  long  period 
of  time,  although  later  at  longer  intervals.  Massage  is 
best  applied  early  in  the  morning  in  the  fasting  condition 
of  the  patient.  During  its  employment  no  i..tlier  remedy  for 
constipation  should  be  administered  unless  the  latter  has 
lasted  several  days  and  gives  rise  to  various  symptoms. 

Auto-massage  may  also  be  of  benefit.  This  may  be 
carried  out  by  the  patient  himself,  kneading  his  abdo- 
men principally  over  the  course  of  the  large  bowel  with 
his  right  hand  or  by  means  of  some  instrument  adapted 
for  this  purpose.  Sahli  was  the  first  to  recommend  the 
use  of  a  cannon-ball,  weighing  about  three  to  five  pounds. 
These  balls  may  be  wrapped  in  flannel  and  rolled  over  the 
abdomen  for  about  five  to  ten  minutes.  This  procedure  is 
best  performed  early  in  the  morning  in  bed  in  the  fasting 
condition  of  the  patient.  The  ball  is  best  rolled  over  the 
abdomen  in  a  spiral  direction,  principally  along  the  course 
of  the  colon.  But  the  other  parts  of  the  abdomen  should 
also  be  subjected  to  this  procedure.  The  flannel  covering 
the  ball  may  be  left  off  if  desired.     Dr.  A.  Rose,'  of  New 

'  Illoway  :  "Constipation  in  Adults  and  Children.  "  New  York,  1897. 
*  A.  Rose  :  New  Yorker  raedizinische  Monatsschrift,  January,  1893. 


308  DISEASES  OF  THE  INTESTINES. 

York,  has  practised  this  method  quite  extensively  and 
warmly  recommends  its  use.  Dr.  Arthur  Kahn,'  also  of 
New  York,  has  invented  an  apparatus  for  auto-massage 
which  may  also  be  used  for  this  purpose.  Rosenheim  '^ 
suggests  using  auto-massage  in  the  following  manner :  The 
patient  in  an  upright  posture  makes  short  palpating  strokes 
with  the  fingers  of  his  right  hand  inclined  somewhat  in- 
wardly over  his  abdomen  for  several  minutes.  In  this 
procedure  also  the  course  of  the  colon  is  especially  to  be 
considered. 

(h)  Gymnastic  exercises.  Exercises  which  bring  into 
play  especially  the  muscles  of  the  abdomen  are  of  great 
benefit.  Exercises  on  the  horizontal  bar,  horseback  rid- 
ing, mountain  climbing,  skating,  rowing,  bicycle  riding, 
are  all  beneficial,  provided  these  sports  are  not  kept  up 
for  too  long  a  time,  and  do  not  cause  a  superabundant 
loss  of  water  by  extensive  perspiration. 

Indoor  gymnastic  exercises  may  also  be  used.  Bend- 
ing of  the  body,  rotations  of  the  trunk,  especially  in  a 
siting  posture,  quickly  drawing  up  the  knees  toward  the 
thorax  in  the  recumbent  position,  also  alternate  squatting 
and  rising  are  of  special  benefit.  The  passive,  so-called 
Swedish  movements  may  also  be  employed  either  in  a 
Zander  Institute  or  manually  by  a  nurse.  Massage  and 
these  exercises  are  best  applied  in  conjunction. 

(c)  Electricity.  Percutaneous  electrization  (principally 
faradization)  of  the  abdomen  has  been  recommended  by 
some  writers  as  a  cure  for  constipation.  Recently  direct 
electrization  of  the  intestine,  applying  one  electrode  to  the 
rectum  and  the  other  over  the  abdominal  wall,   has  been 

•  A.  Eahn  :  Centralblatt  fUr  Cbirurgie  und  orthopadische  Mechanik, 
Berlin.  1889,  Bd.  v.,  p.  4. 
«  Th.  Rosenheim  :  "  Krankheiten  des  Danns,  "  1893,  p.  513. 


CONSTIPATION.  309 

used.  Boudet's  rectal  electrode  is  best  adapted  for  this 
purpose,  especially  when  galvanization  is  employed.  The 
insertion  of  one  electrode  in  the  stomach  and  the  other  in 
the  rectum,  as  suggested  by  Kussmaul  and  Leubuscher,' 
has  not  come  into  use  to  any  extent. 

Electricity  seems  to  act  favorably  on  the  intestinal  peri- 
stalsis and  it  is  especially  indicated  in  the  treatment  of 
constipation  in  conjunction  with  massage,  particularly  in 
atony  of  the  bowel.  Doumer '  has  very  recently  recom- 
mended the  use  of  static  electricity.  He  applies  localized 
franklinization  in  the  form  of  sparks  or  "souffles  elec- 
triques  "  for  about  five  to  twelve  minutes  in  the  iliac  fosssB, 
principally  the  left.  By  the  employment  of  this  method 
of  treatment  every  other  day  for  a  period  of  two  to  three 
weeks  Doumer  reports  having  cured  the  most  obstinate 
cases  of  chronic  constipation. 

(cZ)  Hydrotherapentic  means.  Hydrotherapeutic  meas- 
ures may  be  applied  either  alone  or  in  conjunction  with 
the  above-named  mechanical  means.  Hackel'  gives  the 
following  rules :  In  constipation  due  to  atony  of  the  bowels 
use  a  jet  of  water  of  about  the  thickness  of  the  small  finger 
with  the  force  of  two  atmospheres,  first  over  the  epigas- 
trium. The  hose  of  the  mobile  douche  is  then  placed  over 
the  region  of  the  colon.  Charcot's  douche  is  best  adapted 
for  this  purpose,  as  it  allows  a  sudden  change  of  tempera- 
ture. When  using  the  latter  apparatus  the  temperature 
can  be  readily  changed  to  any  degree  desired  during  its 
application.  The  alternations  in  temperature  should  be 
considerable,  often  from  102°  F.  to  120°  F.  Thus  both 
mechanical   and   thermic  effects  come  into  play.     After 

1  Leubuscher :  Centralbl.  f.  klin.  Medicin,  1887,  No.  25. 

^E.  Doumer  et  Musin  :  Annalesd'Electro-Biologie.  1898,  p.  722. 

■^  Jeannot  Hackel :  Deutsche  med.  Wochenschrift.  Jan.  5,  1899. 


310  DISEASES  OF  THE  INTESTINES. 

using  the  douclie  over  the  abdomen,  it  is  applied  over  the 
chest  and  back,  throwing  a  fan-shaped  jet,  the  temperature 
being  kept  constant. 

In  constipation  due  to  spastic  contractions  of  the  bowels 
Hackel  applies  water  under  a  pressure  of  two  and  a  half 
kilograms,  letting  it  flow  in  the  form  of  a  fine  spray.  It 
falls  like  a  fine  rain  on  the  abdomen.  The  temperature  of 
the  water  should  not  be  lower  than  95"  F.  and  not  higher 
than  102°  F.  and  should  not  be  changed.  The  duration  of 
the  douche  is  from  two  to  two  and  a  half  minutes.  The  hose 
is  directed  along  the  course  of  the  colon  while  the  water 
constantly  runs  over  the  epigastrium.  Ninety-six  such 
circuits  over  the  intestines  may  be  made.  Afterward  the 
lower  extremities,  chest  and  back,  are  douched.  The  skin 
of  the  abdomen  must  not -be  subjected  to  vigorous  friction 
after  the  douche ;  the  extremities,  however,  should  be  well 
rubbed.  After  the  douche  the  patient  should  lie  in  bed 
for  about  five  to  ten  minutes,  being  warmly  covered,  and 
then  may  walk  for  about  a  quarter  of  an  hour. 

Cold  sitz  baths  (12°  C.)  for  about  five  minutes  are  also  of 
benefit,  as  well  as  a  Priessnitz  compress  or  Neptune's  gir- 
dle over  the  abdomen  over  night. 

4.  Injections. — Injections  into  the  bowels  of  water  alone 
or  of  water  with  the  addition  of  soap,  vinegar,  common 
table  salt,  or  castor-oil  are  often  used  with  advantage. 
The  amount  of  fluid  required  for  a  purging  effect  varies  in 
different  persons.  As  a  rule  a  pint  to  a  quart  or  one  and 
a  half  quarts  are  necessary.  These  water  injections  should 
be  made  daily  at  the  same  hour  for  a  period  of  three  to 
four  weeks,  and  then  every  other  day  also  for  the  same 
length  of  time. 

Recently  Klemperer '  has  recommended  the  use  of  small 
'  Klemperer ;   "  Therapie  tier  Gegenwart,  "  1899,  p.  48. 


CONSTIPATION.  311 

water  injections  into  the  bowels  at  bed-time.  Half  a 
pint  of  water  is  injected  and  the  patient  is  told  to  re- 
tain the  fluid.  The  latter  is  very  soon  absorbed  by  the 
intestine  and  the  patient  has  an  evacuation  on  the  fol- 
lowing morning.  Klemperer  cured  cases  of  constipation 
by  giving  these  small  water  injections  for  about  three 
weeks  every  day,  and  then  every  other  day  for  the  follow- 
ing two  or  three  weeks. 

Injections  of  sweet  oil  into  the  rectum,  which  have  been 
recommended  by  Kussmaul  and  Fleiner,  are  best  adapted 
for  the  treatment  of  obstinate  cases  of  constipation,  espe- 
cially if  due  to  spasmodic  contraction  of  the  bowel.  The 
injections  should  be  made  in  the  following  way:  Take 
about  one  pint  of  good  olive  oil  and  heat  it  to  the  tem- 
perature of  the  body.  Then  take  a  fountain  syringe  pro- 
vided with  a  soft-rubber  rectal  tube,  and  inject  the  oil  into 
the  rectum.  The  patient  takes  the  injection  while  in  bed, 
and  it  is  advisable  to  have  him  retain  the  oil  as  long  as 
he  can.  I  usually  order  it  to  be  taken  in  the  evening,  so 
that  the  patient  may  fall  asleep  at  once  and  retain  it  over 
night.  The  following  day  the  oil  is  passed  and  an  evacua- 
tion follows.  If  the  patient  is  treated  for  two  to  three 
weeks  with  oil,  the  spasmodic  condition  will  subside.  The 
oil  injections  should  then  be  given  every  other  night  for 
a  period  of  two  weeks,  thereafter  twice  a  week  for  some 
time,  then  once  a  week  for  several  months. 

Injections  of  glycerin,  which  were  first  recommended 
by  Anacker,'  are  also  beneficial.  Two  to  four  grams  of 
glycerin  are  dissolved  in  about  three  to  four  ounces  of 
water  and  injected  into  the  rectum.  An  evacuation  of 
the  bowels  results  in  a  very  ^hort  time,   ten  to  twenty 

'  Anacker:  "  Das  Purgativ  Oidtmann.  "  Deutsche  nied.  Wochenschr., 
1887,  p.  823. 


312  DISEASES  OF  THE  INTESTINES. 

minutes.  The  glycerin  may  also  be  given  in  the  form 
of  a  suppository,  acting  the  same  way.  While  this  mode 
of  treatment  is  very  convenient  to  produce  an  evacuation 
of  the  bowels,  it  should  not  be  resorted  to  daily,  as  the 
bowel  is  thereby  greatly  irritated. 

Similar  in  its  action  but  less  harmful  is  Flatau's '  method 
of  applying  boric  acid  directly  to  the  rectum.  Boric-acid 
powder,  about  one  to  three  grams,  may  be  inserted  into 
the  rectum  with  the  finger  or  blown  into  it  by  means  of  a 
powder-blower  through  the  anus.  A  movement  of  the  bow- 
els occurs  half  an  hour  to  three  hours  later. 

5.  Purging  Medicaments. — In  many  instances  of  habitual 
constipation  the  use  of  drugs  must  be  resorted  to.  As  a 
general  rule  we  should  administer  as  mild  cathartic  rem- 
edies as  possible,  and  instead  of  increasing  the  dose  we 
should  rather  try  to  reduce  it  gradually,  and  ultimately 
relieve  the  constipation  without  the  help  of  cathar- 
tics. 

The  various  preparations  of  rhubarb  are  very  serviceable. 
Vinum  rhei  and  tinctura  rhei  aromatica  or  dulcis  may  be 
given  in  doses  of  from  half  a  teaspoon  to  one  teaspoonful. 
Rhubarb  may  also  be  given  as  a  powder  in  conjunction 
with  calcined  magnesia  and  bicarbonate  of  soda,  as  for  in- 
stance : 

^  Pulv.  rad.  rhei, 

Magnes.  ustae, 

Sod.  bicarb fia  20.0  (3  v.) 

M.  f.  pulv.  D.  ad  scatulam.  S.  One-half  teaspoonful  two  or  three 
times  a  day.  • 

Pulvis  glycyrrhizse  compositus  is  also  a  very  suitable  prep- 
aration.    It  can  be  given  in  teaspoonful  doses  at  night  or 
in  the  morning.     It  has  the  following  composition : 
'  Flatau:  Berl.  klin.  Wochenschr.,  1891,  p.  231. 


CONSTIPATION,  313 

^  Fol.  sennsB, 

Rad.  glycyrrhizae aa  10.0  (  3  iiss.) 

Fruct.  fa'niculi, 

Sulph.  depur aa    5.0  (  3  ii) 

Sacch.  alb 30.0  ( |  i.) 

Aloes  is  another  very  efficient  and  popular  remedy.  It 
effects  a  movement  of  the  bowels  in  about  eight  to  twelve 
hours  after  its  ingestion  and  does  not  cause  any  griping. 
I  often  give  the  following  prescription : 

I?  Aloes 1.0  (gr.  XV.) 

Extr.  belladonnae, 

Extr.  stryclm aa  0.3  (gr.  v.) 

Extr.  et  pulv.  glycyrrhizae q.a. 

Ut  f.  pil.  No.  XX.     S.  One  pill  twice  daily. 

Of  the  newer  remedies  podophyllin  and  cascara  sagrada 
are  very  valuable.  Podophyllin  is  given  in  doses  of  one- 
sixth  to  one-third  of  a  grain  twice  a  day.  I  use  the  fol- 
lowing prescription : 

I^  Podophyllin 0.3  (gr,  v. ) 

Extr.  physostigmatis, 

Extr.  nuc.  vomic aa  0.5  (gr.  viiss.) 

M.  f.  cum  extr.  et  pulv.  glycyrrhizae  q.  s.  pil.  No.  xxx.    S.  One  pill 
twice  daily. 

Cascara  Sagrada  may  be  given  in  the  form  of  fluid  extract, 
fifteen  to  twenty-five  drops  twice  daily,  or  cascara  sagrada 
with  maltine,  one  teaspoonful  once  or  twice  daily. 

Syrup  of  figs,  one  teaspoonful  at  night  time,  or  tama- 
rind, also  one  teaspoonful,  is  often  of  value. 

Jalap  and  colocynth  belong  to  the  stronger  drastic  rem- 
edies, and  hardly  ever  find  a  place  in  the  treatment  of  the 
cases  under  consideration.  Huuyadi  Janos  water,  Fried- 
richshaller,  Homburger  or  Kakoczy  waters,  Apenta,  Ru- 
biuat  and  the  like  are  also  sometimes  of  benefit.  Thej* 
should,  however,  not  be  used  for  a  long  period  of  time  in 
cases  of  auBBmia  and  neurasthenia. 


CHAPTER  XL 

NEKVOUS  AFFECTIONS  OF  THE  INTESTINES. 

MOTOR  NEUROSES. -(Co;jf*/iwed.) 

Paralysis  of  the  Intestines. 

Partial  paralysis  of  the  intestines  may  occur  and  give 
rise  to  symptoms  resembling  a  complete  occlusion  of  the 
intestinal  lumen.  Paralysis  arising  in  consequence  of  a 
mechanical  obstacle  to  the  passage  of  the  intestinal  con- 
tents has  been  described  above.  Here  we  shall  deal  with 
primary  paralysis  of  the  intestine  without  any  organic  ob- 
stacle. In  this  condition  the  peristaltic  motion  of  this 
organ  is  absent.  The  passage  of  fecal  matter  is  thereby 
interrupted  and  symptoms  of  obstruction  result. 

Henrot '  distinguishes  three  forms  of  intestinal  paraly- 
sis: 

1.  Direct  paralysis  of  a  portion  of  the  intestine  caused 
by  alterations  of  its  walls.  Thus  an  intestinal  coil  may 
become  paralyzed  after  repeated  forced  reposition  of  a 
hernia  or  after  it  has  been  incarcerated  in  the  hernial 
pouch  for  a  long  time.  The  paralysis  may  also  occur  as  a 
consequence  of  a  direct  trauma  or  after  extensive  abdomi- 
nal operations,  and  finally  after  various  chronic  inflamma- 
tory and  ulcerative  processes  of  the  intestine  (enteritis, 
tuberculosis,  dysentery). 

2.  The  paralysis  is  caused  indirectly  in  consequence  of 

'  Henrot :  "Des  Pseudo-etranglements,  "  Paris,  1865. 


INTESTINAL  PARALYSIS.  315 

a  reflex  nervous  action.  Thus  contusion  of  the  testicles, 
inflammation  of  a  hydrocele,  abscesses  of  the  abdomen  may 
inhibit  the  abdominal  nerve  centre  in  such  a  way  that  the 
peristalsis  ceases,  although  this  is  of  \ery  rare  occurrence. 

3.  The  intestinal  i^aralysis  may  result  from  general  neu- 
roses (hysteria),  from  psychoses  (melancholia,  hypochon- 
dria), or  from  affections  of  the  central  nervous  system 
(meningitis,  brain  tumors,  tabes  dorsalis,  myelitis,  etc.). 

Besides  these  three  groups,  Avhich  are  all  of  a  more  or 
less  acute  character,  Rosenheim  also  mentions  paralysis  of 
the  intestines  as  a  consequence  of  coprostasis  due  to  atony 
of  this  organ,  which  condition  is  less  acute  and  more  pro- 
tracted. The  patient,  as  a  rule,  has  suffered  from  consti- 
pation for  a  long  time.  Evacuation  of  the  bowels  has  been 
artificially  produced  only  after  the  appearance  of  many 
annoying  symptoms.  At  last  the  usual  remedies  refuse  to 
work  and  the  patient  now  becomes  a  chronic  sufferer. 
Dyspepsia,  intense  meteorism,  and  palpitations  of  the 
heart  are  present.  The  ingestion  of  food  grows  smaller 
every  day  and  the  patient  becomes  weaker.  This  condition 
may  last  for  weeks  and  months,  and  if  no  radical  remedies 
are  resorted  to,  the  patient  may  ultimately  be  seized  with 
fecal  vomiting  and  die  of  the  intestinal  paralysis. 

According  to  Rosenheim,  a  sudden  attack  of  serious  in- 
testinal obstruction  in  a  patient  suffering  from  chronic 
constipation  is,  as  a  rule,  not  caused  by  paralysis  of  the 
intestine,  but  rather  by  an  occlusion  of  the  intestinal  lu- 
men through  hardened  fecal  matter. 

The  diagnosis  of  intestinal  paralysis  can  be  made  if  all 
the  other  numerous  factors  causing  ileus  can  be  excluded 
and  one  of  the  above-mentioned  etiological  points  can  be 

discovered. 

The  treatment  of  these  cases  consists  in   the  applica- 


316  DISEASES  OF  THE  INTESTINES. 

tion  of  electricity  (recto-abdominal  galvauization),  niaa- 
sage,  and  purgative  high  rectal  injections.  Cases  in 
which  the  paralysis  is  caused  by  chronic  constipation  must 
be  treated  by  high  injections  of  either  ice  water  two  hun- 
dred to  five  hundred  grams,  or  water  with  the  addition  of 
two  hundred  to  five  hundred  grams  of  oil.  These  injec- 
tions should  be  applied  twice  or  three  times  a  day  for  sev- 
eral days  in  succession  until  a  satisfactory  result  has  been 
obtained.  Massage  and  electricity  can  be  used  in  addition 
to  these  injections.  Internal  purgatives,  even  croton  oil, 
are  not  efficacious  in  this  class  of  cases.  The  use  of  mer- 
cury', however,  in  doses  of  three  hundred  to  eight  hundred 
grams  is  here  of  great  value.  In  cases  in  which  the  lower 
part  of  the  colon  is  the  seat  of  the  paralysis,  the  stagnant 
fecal  matter  must  be  removed  with  the  hand  before  the 
rectal  injection  is  resorted  to. 

Proctospasmus,  or  Spasm  of  the  Rectum. 

This  condition  consists  in  attacks  of  painful  contraction 
of  the  sphincters  of  the  rectum  and  is  in  most  instances 
a  secondary  aflfection.  It  is  mostly  found  in  inflammatory 
and  ulcerative  processes  of  the  rectum  and  colon,  in  fissure 
of  the  anus,  and  also  in  inflammatory  diseases  of  neighbor- 
ing organs,  bladder,  prostate,  uterus. 

Spasm  of  the  rectum  may,  however,  occur  also  indepen- 
dently as  a  primary  nervous  affection.  As  such  it  is  prin- 
cipally met  with  in  individuals  with  a  nervous  taint,  and 
in  diseases  of  the  si)inal  cord.  The  attacks  of  proctospas- 
mus differ  in  intensity  and  also  in  duration.  Sometimes 
they  last  only  a  short  while,  a  few  minutes,  sometimes  sev- 
eral hours  or  even  days.  In  the  milder  form  defecation  is 
accompanied  by  intense  pains  and  takes  place  only  after 
great  effort.     In  the  severer  forms  there  is  a  strong  desire 


PARALYSIS  OF  THE  SPHINCTERS.  317 

for  defecation,  but  notwithstanding  the  most  intense  paina 
and  great  straining  there  is  no  movement  of  the  bowels. 
If  these  attacks  last  several  hours  they  greatly  weaken  the 
patient  and  render  him  very  despondent.  The  anus  is  very 
sensitive  to  touch,  and  a  digital  examination  of  the  rectum 
during  the  spasm  ia  hardly  ever  possible.  A  thorough 
examination  of  the  rectum  can  be  made  only  during  anaes- 
thesia. In  instances  of  very  severe  proctospasmus  a  tran- 
sient paresis  or  paralj'sis  of  the  sphincter  muscles  may 
result. 

The  diagnosis  of  proctospasmus  is  easy,  as  the  symp- 
toms are  ver}^  distinct.  The  diagnosis  of  the  primary  ner- 
vous form  will  be  made  if  organic  diseases  of  the  rectum 
and  of  the  neighboring  organs  can  be  excluded. 

The  treatment  must  be  directed  principally  toward  the 
primary  affection.  In  cases  of  nervous  proctospasmus  the 
treatment  should  be  symptomatic  and  consist  in  the  use 
of  narcotic  remedies.  In  severe  forms  of  this  malady  hy- 
podermic injections  of  morphine  must  be  resorted  to.  In 
some  instances  a  forcible  divulsion  of  the  sphincter  under 
chloroform  narcosis  may  become  necessary. 

Paresis  and  Paralysis  of  the  Sphincters  of  the  Anus. 

Paralysis  of  the  anal  sphincters  occurs  frequently  in  con- 
sequence of  long-lasting  affections  of  the  rectum.  Some- 
times over-exertion  of  these  muscles  (tenesmus)  ultimately 
leads  to  exhaustion.  Occasionally  ulcerations  and  infiltra- 
tions of  the  rectum  involve  also  the  sphincters  or  entirely 
destroy  them,  thus  annulling  their  functions.  The  tonicity 
of  the  sphincter  muscles  may  be  impaired  in  i)er8ons  who 
have  suffered  for  a  long  time  from  an  accumulation  of 
fecal  matter  in  the  lower  portions  of  the  bowel.  Tlie  mus- 
cular apparatus  being  over-irritated  for  a  long  time  becomes 


318  DISEASES  OF  THE  INTESTINES. 

weakened  and  exhausted.  Diseases  of  the  brain  and  spi- 
nal cord,  leading  to  inhibition  of  the  will  power,  may  like- 
wise cause  paralysis  of  the  sphincters. 

Atony,  paresis,  and  paralysis  form  different  degrees 
of  this  affection.  Some  patients  are. not  able  to  keep  the 
rectum  tightly  closed,  and  a  small  amount  of  secretion  con- 
tinually penetrates  through  the  anus.  After  defecation 
they  have  the  sensation  of  not  having  finished  the  act. 
Sometimes  there  may  be  an  involuntary  movement  of  the 
bowels  in  consequence  of  the  loss  of  the  contractile  power. 
This,  however,  occurs  only  after  strong  excitement,  intense 
bodily  exertion,  during  urination,  and  rarely  in  walking. 

In  case  the  paralysis  of  the  sphincters  is  complete,  flatus 
and  fecal  matter  will  escape  involuntarily  even  in  a  state  of 
rest.  In  paralysis  resulting  from  proctitis,  hemorrhoids, 
stricture,  etc.,  there  is  a  continuous  dripping  of  a  muco- 
sanguinary  secretion  which  greatly  irritates  the  skin  sur- 
jrounding  the  anus. 

Diagnosis. — Paralysis  of  the  anal  sphincter  can  be  recog- 
nized very  easily.  The  anus  appears  patulous  and  the 
anal  folds  have  disappeared.  Two  and  even  three  fingers 
may  be  introduced  into  the  rectum  without  encountering 
any  resistance.  In  making  the  diagnosis  of  a  purely  ner- 
vous paralysis  anatomical  lesious  must  first  be  excluded. 
This  is  done  by  means  of  a  thorough  examination  of  the 
rectum  with  a  speculum. 

Prognosis. — Paralysis  resulting  from  anatomical  lesions 
of  the  rectum  gives  an  unfavorable  prognosis.  In  the  purely 
neurotic  form,  however,  the  prognosis  is  much  better. 

Treatment. — It  is  of  great  importance  to  secure  a  thor- 
ough evacuation  of  the  bowels,  which  is  best  done  by  rec- 
tal injections  of  water  twice  dailv.  Paralysis  due  to  fecal 
impaction'  ac  such,  can  be  entirely  remedied  by  the  just 


PERISTALTIC  RESTLESSNESS.  319 

mentioned  measures  alone.  Thus  Wallace  '  reports  a  cure 
in  a  case  of  a  nine-year-old  boy  who  was  troubled  for 
three  years  with  incontinency  of  faeces,  which  dropped  out 
whenever  he  walked.  The  patient  was  treated  with  water 
enemas  to  which  castor  oil  had  been  added,  and  later  on 
with  injections  of  water  with  the  addition  of  alum.  After 
a  month's  treatment  he  entirely  recovered. 

In  paralysis  due  to  affections  of  the  central  nervous  sys- 
tem electricity  and  massage  may  be  of  benefit.  Hypoder- 
mic injections  of  strychnine  (0.001  to  0.0015  pro  dose) 
into  the  anal  folds  have  been  recommended  by  Rosen- 
heim. Cases  in  which  the  paresis  of  the  sphincter  is  due 
to  a  difficulty  in  urination  and  a  continuous  straining  in 
order  to  void  the  bladder,  the  paresis  will  be  improved  by 
artificially  emptying  the  bladder  by  means  of  a  catheter  for 
a  considerable  length  of  time. 

Peristaltic  Restlessness  of  the  Intestines. 

Definition. — Increased  peristaltic  motions  of  the  intes- 
tines in  such  a  way  that  they  become  visible  through  the 
abdominal  walls. 

Etiology  and  Symptomatology. — "While  in  the  normal 
state  intestinal  peristalsis  is  accomplished  without  being 
visible  or  making  itself  felt,  in  pathological  conditions 
increased  peristalsis  may  exist  which  can  be  easily  per- 
ceived through  the  abdominal  walls  and  which  is  usually 
accompanied  by  distinct  noises  (borborygmi).  Increased 
intestinal  peristalsis  may  accompany  any  complete  or  in- 
complete occlusion  of  the  intestinal  lumen  or  it  may  be 
caused  by  purely  neurotic  influences.  Here  only  the  lat- 
ter form  is  dealt  with,  as  the  former  condition  is  discussed 
in  connection  with  the  organic  lesions  causing  it. 
>  Wallace :  St.  Barthol.  Hosp.  Report,  1888. 


320  DISEASES  OP  THE  INTESTINES. 

Usually  peristaltic  restlessness  of  the  intestines  occurs  in 
the  form  of  attacks,  lasting  several  hours  in  succession  and 
reappearing  after  more  or  less  long  periods  of  time.  In 
some  instances  the  patients  complain  of  various  movements 
and  noises  within  the  abdomen  due  to  the  increased  intes- 
tinal peristalsis,  while  pain  is  absent.  In  other  instances 
the  above  sensations  are  now  and  then  interspersed  with 
severe  colicky  pains.  The  majority  of  cases  of  peristaltic 
restlessness  of  the  intestines  is  accompanied  rather  by  con- 
stipation, seldom  there  are  either  normal  evacuations  or 
diarrhoea.  In  some  instances  the  exaggerated  peristaltic 
motions  continue  even  after  intestinal  digestion  has  been 
completed,  and  are  accompanied  by  painful  sensations. 
Peristaltic  restlessness  of  the  intestines  is  occasionally  as- 
sociated with  peristaltic  restlessness  of  the  stomach. 

Peristaltic  restlessness  of  the  intestines  is  principally 
met  with  in  nervous  x^ersons,  in  the  hysterical  and  hypo- 
chondriacal. Occasionally,  however,  it  occurs  in  persons 
who  do  not  present  any  other  nervous  symptoms.  In 
women  this  condition  may  exist  during  the  monthly  periods 
or  pregnancy.  In  some  persons  it  appears  after  the  inges- 
tion of  highly  spiced  or  indigestible  foods,  after  the  exces- 
sive use  of  tobacco,  after  great  i^ychical  excitement  or  too 
much  brain  work.  In  other  cases,  however,  none  of  these 
etiological  factors  can  be  discovered. 

Diagnosis. — The  diagnosis  of  peristaltic  restlessness  of 
the  intestines  is  made  whenever  pronounced  intestinal  mo- 
tions are  visible  through  the  abdomen.  The  nervous  char- 
acter of  this  condition  is  recognized,  first,  after  exclusion 
of  organic  affections  of  the  intestines ;  secondly,  by  its  pe- 
riodic appearance. 

The  prognosis  is  favorable. 

Treatment. — In  the  first  place  it  is  of  importance  to  in- 


METEORISM.  321 

vigorate  the  entire  organism  and  especially  improve  the 
condition  of  the  nervous  system.  With  regard  to  diet 
sufficient  quantities'  of  food  should  be  given,  but  too  spicy 
and  indigestible  nourishment  should  be  excluded.  In 
cases  accompanied  by  some  abnormality  of  the  bowels 
their  function  should  be  regulated.  The  bromides,  valer- 
ian, and  asafetida  are  of  decided  value.  Drinking  of  warm 
water  or  tea  and  hot  applications  are  useful  during  the 
attack.  Arsenic  alone  or  in  combination  with  iron  is  of 
benefit  in  cases  combined  with  anaemia.  If  the  condition 
assumes  a  violent  character  and  is  accompanied  by  severe 
pains,  a  small  dose  of  an  opiate,  alone  or  in  combination 
with  belladonna,  is  appropriate.  If  the  intestinal  restless- 
ness appears  at  night  time  and  prevents  the  patient  from 
sleeping,  chloral  hydrate,  sulphonal,  or  trional  may  be  ad- 
ministered. Electricity  and  massage  of  the  abdomen  have 
been  variously'  recommended,  but  neither  of  the  two  ap- 
pears to  me  to  be  of  great  value  in  this  condition.  Change 
of  climate  and  surroundings  is  often  of  benefit. 

Meteorism. 

Meteorism,  tympanites,  or  flatulency  signifies  a  condi- 
tion in  which  there  is  an  excessive  accumulation  of  gas 
in  the  intestinal  tract. 

If  not  caused  b}-  an  organic  obstruction  in  the  bowel  this 
condition  is  due  to  an  abnormal  state  of  the  intestinal  mo- 
tion and  absorption.  Owing  to  the  first  factor  we  describe 
this  anomaly  under  motor  neuroses. 

Etiology. — The  causes  of  the  excessive  accumulation  of 
gas  are :  1,  an  increased  ingestion  of  gases  themselves  or 
of  substances  which  easily  form  them ;  and  2,  a  diminu- 
tion or  impairment  of  their  elimination  from  the  intes- 
tines. The  increased  introduction  of  gases  may  consist  in 
21 


322  DISEASES  OF  THE  INTESTINES. 

swallowing  of  air  or  in  drinking  beverages  highly  charged 
with  carbonic-acid  gas.  In  both  instances  the  gases  prin- 
cipally accumulate  in  the  stomach,  although  a  portion  of 
them  reaches  the  intestines. 

Increased  formation  of  gas  within  the  intestine  is  the 
consequence :  1,  of  various  processes  of  fermentation  and 
disintegration  of  carbohydrates  and  fats,  hydrogen  and 
carbon  dioxide  being  the  i)riucipal  gases ;  2,  of  the  decom- 
position of  proteids  which  produce  besides  the  gases  just 
mentioned  sulphuretted  hydrogen,  carburetted  hydrogen, 
and  methyl  mercaptan.  The  increased  formation  of  gas  is 
mostly  due  to  an  increased  ingestion  of  easily  fermenting 
food. 

A  diminished  elimination  of  the  gases  may  be  due  :  1, 
to  an  inhibition  of  the  passage  of  the  flatus ;  and  2,  to  re- 
tarded absorption.  The  passage  of  flatus  is  inhibited  either 
by  an  intestinal  obstruction  or  occlusion,  or  by  a  paresis 
or  paralj'sis  of  the  intestinal  muscles.  The  latter  condi- 
tion is  found  in  peritonitis  and  in  grave  infectious  diseases, 
after  shock,  in  severe  anaemia,  in  spinal  affections,  and 
also  in  general  neuroses.  Most  cases  of  meteorism,  which 
quickly  appears  and  just  as  quickly  leaves  the  patient,  are 
due  to  paresis  of  the  intestinal  walls  and  are  usually  asso- 
ciated with  a  large  number  of  other  nervous  symptoms. 

Symptomatology. — A  certain  degree  of  tension  about  the 
abdomen,  more  or  less  pronounced,  is  almost  always  expe- 
rienced by  the  patient.  In  some  instances  the  abdomen 
protrudes  in  balloon-shape,  the  region  of  the  navel  being 
principally  involved.  This  picture  is  mostly  met  with  in 
patients  with  relaxed  abdominal  walls.  In  cases  in  which 
the  latter  are  tense  the  accumulation  of  gases  may  push 
the  diaphragm  upward.  Sometimes  the  lungs  and  heart 
are  forced  upward  and  severe  dyspnoea  develops,  which 


iMETEORISM.  323 

in  rare  Instances  may  be  followed  by  asphyxia,  collapse, 
and  even  death.  There  is  a  constant  feeling  of  press- 
ure and  a  desire  to  pass  wind,  while  colicky  pains  are 
also  occasionally  met  with.  As  a  rule  no  flatus  can  be 
passed  or  very  inconsiderable  amounts  at  long  intervals. 

Differing  from  the  form  of  meteorism  just  described  are 
those  cases  in  which  there  is  a  slight  tension  over  the  abdo- 
men and  wind  is  passed  from  the  anus  almost  constantly 
for  a  long  time  with  much  noise.  It  is  highly  improbable 
that  the  gases  emitted  in  this  variety  of  cases  are  really 
produced  in  the  intestinal  tract  for  the  following  reasons : 
1,  there  is  no  considerable  change  in  the  size  of  the  abdo- 
men after  a  repeated  passage  of  considerable  amounts  of 
gas  from  the  anus ;  2,  the  absence  of  relief  felt  by  the  pa- 
tient after  the  passage  of  flatus ;  and  3,  the  almost  odorless 
character  of  these  gases.  Rosenheim  compares  these  cases 
with  those  of  nervous  eructation  from  the  stomach.  While 
in  the  latter  the  air  is  constantly  swallowed  by  the  patient 
and  belched  up  again,  in  the  intestinal  variety  Rosenheim 
assumes  that  the  air  is  constantly  pumped  into  the  rectum 
in  order  to  be  again  emitted  as  flatus. 

The  diagnosis  of  meteorism  is  made  whenever  an  exces- 
sive amount  of  gas  is  discovered  in  the  intestines. 

^\e  progyiosis  will  depend  upon  the  cause  which  creates 
the  tympanites.  If  it  be  due  to  organic  lesions  of  the 
intestines  (occlusion  of  the  lumen)  the  prognosis  is  very 
grave,  while  meteorism  due  to  a  purely  nervous  disturb- 
ance gives  a  favorable  outlook. 

Treatment— In  instituting  a  curative  plan  for  this  affec- 
tion it  will  be  necessary  to  elucidate  the  etiological  factor 
of  the  meteorism.  If  the  latter  is  caused  by  an  obstruc- 
tion of  the  bowel,  this  primary  affection  will  have  to  be 
treated  as  such.     In  most  instances  of  meteorism  of  neu- 


324  DISEASES  OF  THE  INTESTINES. 

rotic  origin  the  following  points  are  of  importance :  Drinks 
and  foods  containing  or  forming  a  large  amount  of  gas 
should  be  prohibited;  thus  all  carbonated  waters,  beer, 
champagne,  and  cider  should  be  avoided.  Fresh  fruits,  all 
kinds  of  cabbage,  leguminous  foods,  potatoes,  coarse  rye 
bread,  sweetened  cake,  rich  gravies  should  be  carefully  ab- 
stained from.  These  rules  apply  not  only  when  the  mete- 
orism  is  fully  developed  but  in  patients  with  a  disposition 
to  flatulency. 

Formerly  numerous  intestinal  antiseptics  were  given 
with  the  object  of  lessening  the  fermentative  processes 
in  the  bowels.  Recently,  however,  the  general  view  jire- 
vails  that  they  are  of  no  benefit  whatever.  Benzonaphthol, 
salol,  and  salicylate  of  sodium  are  still  regarded  as  the  most 
efficient  in  this  respect  and  may  be  tried  in  suitable  cases. 
They  can  perhaps  be  advantageously  administered  in 
Sahli's '  glutoid  capsules  in  order  to  prevent  their  ab- 
sorption in  the  stomach.  Calcined  magnesia,  lime  water, 
charcoal,  testa  prseparata,  and  subnitrate  of  bismuth  are 
given  with  the  intention  of  absorbing  the  gas,  although 
their  actual  effect  in  this  respect  can  naturally  be  only 
very  limited. 

The  following  drugs  are  believed  to  have  a  beneficial 
influence  in  diminishing  the  gas,  especially  in  mild  forms 
of  flatulency :  poppy-seed,  peppermint,  spearmint,  thyme, 
cinnamon,  cloves,  nutmeg,  anise,  fennel.  These  are  best 
given  in  infusions.  It  has  not  as  yet  been  scientifically 
proven  whether  the  reaction  following  their  administra- 
tion is  due  to  a  slight  increase  of  the  intestinal  peristalsis. 
Brunton  and  Cash'  are  of  the  opinion  that  the  carmin- 
atives, such  as  asafetida  and  oil  of  cloves,  have  a  distinct 

•  Sahli :  Deutsche  nied.  Wochenscbr. ,  1897,  No.  1. 

»  Brunton  and  Cash  :  St.  Barthol.  Hosp.  Report,  1887. 


METEORISM.  325 

effect  upon  the  absorption  of  several  gases  (carbonic-acid 
gas  and  sulphuretted  hydrogen). 

The  removal  of  the  gas  per  vias  naturales  through  the 
anus  is  the  most  efficient  therapeutic  measure.  This  can 
be  done  through  cathartic  remedies  whenever  there  is  no 
contraindication  against  their  use.  Large  cleansing  ene- 
mas of  water,  with  the  addition  of  a  teaspoonful  of  essence 
of  peppermint  or  oil  of  turpentine  emulsified  with  an  egg 
to  a  quart,  are  of  benefit. 

When  there  are  no  anatomical  lesions,  massage  of  the 
abdomen  and  faradization  may  be  of  advantage.  This 
also  applies  to  friction  of  the  abdomen  with  a  cloth  dipped 
in  some  alcoholic  solutions  of  aromatics  or  ethereal  oils 
(linimentum  saponis,  oleum  carvi,  cajuputi,  terebinthinae, 
etc.).  The  introduction  of  a  tube  into  the  rectum  may  be 
helpful  in  favoring  the  escape  of  gas  frem  the  lower  parts 
of  the  colon.  In  desperate  cases  in  which  the  meteorism 
has  reached  such  dimensions  as  to  endanger  life,  punc- 
ture of  the  intestine  through  the  abdomen  with  the  trocar 
has  to  be  resorted  to.  The  meteorism  of  hysterical  per- 
sons often  requires  no  treatment,  as  it  usually  disappears 
of  itself.  Sometimes,  however,  it  is  very  obstinate  to  all 
therapeutic  measures. 

SENSORY  NEUROSES  OF  THE  INTESTINES. 

While  normally  no  sensations  originate  in  the  intestinal 
canal  which  become  perceptible  even  during  digestion,  in 
pathological  conditions  this  organ  may  be  the  seat  of  the 
most  painful  feelings.  The  latter  originate  in  the  fibres  of 
the  sympathetic  nerve.  Most  of  the  sensory  neuroses  of 
the  intestine  consist  in  an  increased  excitability  of  the  sen- 
sory filaments  of  these  nerves.     There  are,  however,  a  few 


326  DISEASES  OF  THE  INTESTINES. 

conditions  in  which  a  lessened  sensibility  exists.  The 
latter  relates  principally  to  the  sensory  nerves  of  the  rec- 
tum. Normally  the  entrance  of  fecal  matter  into  the  rec- 
tum mechanically  irritates  these  nerves  and  creates  a  desire 
for  an  evacuation,  while  a  lessened  irritability  of  the  rectal 
nerves  may  fail  to  produce  the  above  sensation. 

Enteralgia. 

Synonyms. — Intestinal  colic.     Neuralgia  mesenterica. 

Definition. — Pains  in  the  intestines.* 

Etiology. — Enteralgia  is  present  in  most  organic  lesions 
of  the  intestines.  Enteralgia  of  purely  neurotic  origin, 
however,  which  is  considered  in  this  chapter,  occurs  inde- 
pently  of  any  anatomical  lesions  of  the  intestinal  walls. 

Sometimes  abnormally  strong  stimuli  may  be  evolved 
within  the  intestinal  canal,  producing  painful  sensations. 
These  stimuli  may  be  of  a  mechanical,  chemical,  or  ther- 
mal character.  Thus,  a  conglomeration  of  intestinal 
worms,  foreign  bodies,  gall  stones,  or  enteroliths  may  i^ro- 
duce  intense  colic.  Sometimes  hardened  fecal  masses 
press  upon  the  sensory  nerves.  The  intestinal  lumen 
being  temporarily  occluded  by  these  masses,  gases  collect 
above  this  space  and  increase  the  tension  within  the  intes- 
tinal canal,  thus  giving  rise  to  intense  pain  (wind  colic, 
colica  flatulans,  which  is  quite  often  seen  in  children). 
Sometimes  the  ingestion  of  very  coarse  foods,  indigestible 
substances,  tainted  foods,  too  cold  beverages,  highly  fer- 
mented drinks  cause  enteralgia.  In  the  gouty  diathesis  it 
may  precede  a  gouty  attack  or  replace  it.  Similar  to  these 
conditions  in  which  the  enteralgia  takes  its  origin  from 
toxic  substances  contained  in  the  blood  and  irritating  the 
intestinal  nerves,  is  also  the  intestinal  colic  met  with  in 
chronic  intoxication  from  lead  or  copper. 


ENTERALGIA.  327 

Aside  from  these  forms  of  enteralgia  due  to  a  certain 
discoverable  irritating  factor,  it  may  also  result  from  a 
I)erverted  state  of  the  sensory  intestinal  nerves  themselves. 
The  latter  group  is  principally  found  in  patients  affected 
with  hysteria,  or  spinal  troubles,  although  it  may  also  be 
of  a  reflex  nature  due  to  abnormal  conditions  of  neighbor- 
ing organs,  kidnej  s,  bladder,  uterus,  ovaries,  and  liver. 

Symptomatology.  —  The  symptomatology  of  enteralgia 
presents  quite  a  varied  picture,  in  many  instances  depend- 
ing upon  the  cause  of  the  enteralgia.  If  the  neuralgia 
mesenterica  is  due  to  an  error  in  diet,  it  usually  begins 
with  gastric  disturbances,  belching,  nausea,  vomiting,  and 
anorexia.  In  cases  in  which  an  accumulation  of  fecal  mat- 
ter produces  the  enteralgia,  obstinate  constipation  and  flat- 
ulence, occasionally  alternating  with  diarrha?a,  precede  the 
attack.  In  chronic  lead  poisoning  there  are  present  a 
bluish  line  around  the  gums  near  the  teeth,  retarded  pulse, 
and  oliguria. 

The  principal  symptom  of  neuralgia  mesenterica  is  pain 
within  the  intestine.  It  seldom  appears  suddenly  and  with 
great  violence.  As  a  rule,  the  pains  are  at  first  of  light 
character  and  gradually  increase  in  intensity.  They  are 
of  a  cutting,  throbbing,  or  pinching  nature,  and  are  ex- 
perienced usually  in  one  and  the  same  abdominal  area, 
most  often  in  the  region  of  the  navel.  Starting  from  this 
spot  they  radiate  toward  the  back,  the  loins,  the  thighs, 
and  the  testicles.  In  some  cases  the  pain  wanders  from 
one  area  to  another  and  may  be  felt  at  different  times  in 
the  most  varied  regions  of  the  abdomen.  In  the  latter 
instances  the  pains  are  accompanied  by  a  visible  peristaltic 
restlessness  of  the  intestine,  often  producing  gurgling 
noises. 

In  mild  cases  the  pain  is  quite  endurable,  and  often  lasts 


328  DISEASES  OF  THE  INTESTINES. 

but  a  short  while.  In  severer  forms  of  enteralgia,  how- 
ever, the  pains  may  be  of  extreme  violence,  and  in  weak 
I)atients  may  produce  syncope,  while  in  the  more  robust 
they  may  give  rise  to  attacks  of  imnting  and  crying.  The 
face  grows  pale  and  assumes  an  expression  of  intense  suf- 
fering. The  forehead  is  covered  with  cold  perspiration 
and  the  extremities  are  cold.  The  entire  picture  resem- 
bles very  much  that  of  shock. 

Pressure  in  many  instances  slightly  alleviates  the  pain, 
and  for  this  reason  the  patients  often  press  their  hand  or 
some  other  hard  substance  against  their  abdomen.  For 
the  same  reason  they  are  often  found  lying  on  their  abdo- 
men, pressing  the  latter  against  the  mattress.  In  cases, 
however,  in  which  the  intestinal  tract  is  filled  with  gas 
and  the  abdomen  therefore  in  a  tense  condition,  even  very 
slight  pressure  increases  the  pains.  Under  these  circum- 
stances a  suspicion  of  peritonitis  often  arises.  Ultimately 
the  pains  gradually  decrease,  and  disappear  much  quicker 
if  the  accumulated  fecal  masses  and  gases  have  been  evacu- 
ated spontaneously  or  by  means  of  injections.  The  attack 
is"  then  over: 

Spastic  contractions  of  the  intestine  are  often  encoun- 
tered, especially  when  the  pains  are  of  intense  character. 
If  these  contractions  involve  a  large  part  of  the  intestine, 
as  is  often  the  case  in  lead  colic,  the  abdomen  appears 
trough-shaped.  The  abdominal  walls  are  quite  tense  and 
often  very  rigid.  In  case  the  spasms  are  limited  to  iso- 
lated intestinal  coils,  the  abdomen  is  not  drawn  in  and  at 
some  places  where  there  are  intestinal  coils  overfilled  with 
fecal  matter  and  gas,  may  asymmetrically  protrude.  In 
stercoral  and  wind  colic  the  abdomen  usually  is  tympanitic. 

Constipation  is  almost  always  present.  Frequently 
there  is  also  a  retention  of  the  intestinal  gases.     If  the  lat- 


ENTERALGIA.  329 

ter  are  passed  in  considerable  quantity,  the  pains  often 
subside  for  a  short  while,  or,  in  some  instances,  especially 
in  the  so-called  wind  colic,  entirely  disappear. 

The  intensity  and  the  duration  of  the  attack  are  subject  to 
great  variations.  It  may  last  from  a  few  hours  to  several 
days.  The  pains  are  sometimes  but  very  slight,  and  again 
of  such  violence  that  even  large  doses  of  opium  are  hardly 
effective. 

Aside  from  the  above-mentioned  symptoms  there  exist 
quite  often  shortness  of  breath,  palpitations  of  the  heart,  a 
sensation  of  oppression,  tenesmus,  strangury,  hiccough, 
vomiting,  seldom  pollutions  and  priapism.  Occasionally 
cramps  of  the  calves  and  even  general  convulsions  are  ob- 
served. In  cases  of  hysteria  hyperesthesia  of  the  abdomi- 
nal walls  is  encountered. 

Diagnosis. — Enteralgia  is  easil}'^  recognized  when  it  pre- 
sents the  above-described  characteristic  jncture.  Its  neu- 
rotic nature,  however,  will  be  inferred  from  the  following 
features:  It  appears  in  attacks,  and  subsides  suddenly. 
There  are  almost  always  other  nervous  symptoms  present. 
In  enteralgia  due  to  anatomical  lesions  of  the  intestine  the 
pain  is,  as  a  rule,  increased  by  pressure  upon  the  abdomi- 
nal walls.  Another  distinguishing  mark  for  the  latter  is 
that  it  is  more  often  accompanied  by  diarrhoea,  and  that 
the  dejecta  contain  pathological  admixtures  (blood,  mucus, 
rarely  pus). 

With  regard  to  the  differential  diagnosis  the  following 
conditions  which  are  accompanied  by  abdominal  pains  will 
have  to  be  excluded :  Kheumatic  affections  of  the  abdomi- 
nal muscles,  lumbar  abdominal  neuralgia,  hyperesthesia 
of  the  abdominal  walls,  peritonitis,  biliary  and  renal  colic. 

Eheumatism  of  the  abdominal  muscles  is  characterized 
by  the  following  features :   The  pain  is  situated  over  the 


330  '       DISEASES  OF  THE  INTESTINES. 

superficial  area  and  not  within  the  abdominal  cavity.  It 
often  changes  its  seat.  It  is  of  longer  duration  than  enter- 
algia  and  does  not  show  any  distinct  exacerbations  nor 
diffusion.  Pressure  increases  the  pain,  while  rest  in  a  re- 
cumbent position  eases  it.  Anti-rheumatic  remedies  (salol, 
sodium  salicylate,  salipyrin)  subdue  it. 

In  lumbar  abdominal  neuralgia  the  pain  is  localized  on 
the  surface  and  limited  to  one  intercostal  space  which  is 
very  painful  to  pressure.  The  pains  often  radiate  to  the 
back,  the  hypogastrium,  and  the  genital  organs.  Anti- 
neuralgic  remedies  (antipyrin,  antifebrin,  phenacetin)  are 
often  efficient. 

Hypersesthesia  of  the  abdominal  wall  is,  as  a  rule,  met 
with  in  hysteria  and  neurasthenia.  The  pains  are  local- 
ized in  the  superficial  layer.  The  slightest  touch  of  the 
skin  of  the  abdomen  increases  the  pain.  The  faradic  cur- 
rent often  quickly  removes  it. 

In  peritonitis  there  is  almost  always  fever,  and  the  pain 
is  increased  on  pressure.  Meteorism  is  here  much  more 
frequently  encountered  than  in  intestinal  colic.  Frequently 
dulness  in  the  lower  part  of  the  abdomen  (exudation)  is 
observed. 

Biliary  and  renal  colic  are  recognized  by  the  situation 
of  the  pain  which  often  corresjjonds  to  the  location  of  the 
affected  organ.  Besides,  other  symptoms  are  usually  pres- 
ent which  are  characteristic  of  the  latter  (icterus,  strangury). 

Prognosis. — The  prognosis  of  intestinal  colic  is  almost 
always  good  with  regard  to  life,  for  the  attack  usually  ends 
in  recovery.  Exceptional  cases  of  death  have,  however, 
been  observed  by  Oppolzer'  and  Wertheimer." 

Treatment — The  treatment  consists,  first,  in  measures 

'  Oppolzer:  Wiener  med.  Wocbenschr.,  1867. 

*  Wertheimer :  Deutsches  Arch.  f.  klin.  Medicin,  1866,  Bd.  1. 


ENTERALGIA.  331 

directed  toward  the  removal  of  the  cause,  and  secondly, 
toward  the  relief  of  the  pain.  In  most  cases  of  intestinal 
colic  a  thorough  evacuation  of  the  bowels  is  of  benefit. 
For  this  purpose  injecticjus  of  a  considerable  quantity  of 
water  (one  to  two  quarts)  or  of  olive  oil  (one-half  to  one 
pint)  are  very  serviceable.  Mild  cathartic  remedies,  cas- 
tor-oil, calomel,  and  the  like,  may  also  be  administered. 
In  cases  in  which  worms  have  been  found  a  vermifuge  must 
be  given  with  the  cathartic.  If  meteorism  is  quite  pro- 
nounced massage  of  the  abdomen  may  be  tried.  If  the 
colic  is  due  to  an  error  in  diet,  the  latter  must  be  strictly 
regulated.  If  due  to  a  general  cold,  hot  beverages  (tea, 
infusions  of  camomile  and  of  jieppermint),  hot  jjoultices 
over  the  abdomen  are  of  value. 

In  nervous  enteralgia  occurring  in  patients  suffering  from 
hysteria  and  neurasthenia  the  treatment  should  be  directed 
toward  the  improvement  of  the  latter  conditions.  Climate, 
electricitj',  massage,  and  hydrotherapy  play  a  predominant 
part  here. 

The  following  symptomatic  measures  which  serve  to 
subdue  the  pains  are  of  great  importance :  If  the  colicky 
pains  are  quite  severe,  the  administration  of  an  efficient 
dose  of  an  opiate  is  indicated.  Tincture  of  opium  may  be 
given  in  doses  of  fifteen  or  twenty  drops,  or  opium  ex- 
tract, 0.03  to  0.05;  or  morphine,  0.01  to  0.015,  may  be  in- 
jected subcutaneously.  Even  in  cases  in  which  the  colic 
is  due  to  a  retention  of  fecal  matter,  the  narcotics  just 
mentioned  are  indicated,  for  they  relieve  the  spastic  con- 
tractions of  the  intestines. 

During  a  severe  attack  of  intestinal  colic  the  diet  should 
consist  principally  of  liquids,  small  (luantities  of  milk  and 
broth  being  given  at  fre(iuent  intervals  (about  every  two 
hours) .     If  the  attacks  recur  quite  often,  the  application 


332  DISEASES  OF  THE  INTESTINES. 

of  the  galvanic  current  (one  electrode  within  the  rectum, 
negative  pole,  the  other  over  the  abdomen)  is  sometimes 
of  benefit. 

Hypogastric  Neuralgia. 
(Neuralgia  hypogastrica,  Komberg.') 

Enteralgia  limited  to  the  lower  portion  of  the  large 
bowel  is  termed  hyi^ogastric  neuralgia.  In  this  condition 
there  exist  disagreeable,  sometimes  painful  sensations  in 
the  lower  region  of  the  abdomen  and  in  the  lower  parts  of 
the  back,  accompanied  by  a  violent  feeling  of  pressure  in 
the  rectum  and  sometimes  also  in  the  bladder.  In  female 
patients  the  same  sensation  may  also  extend  to  the  uterus 
and  vagina.  Sometimes  the  patient  also  complains  of 
painful  sensations  in  the  perineum  and  the  thighs.  Per- 
sons suffering  from  hemorrhoids  and  women  afflicted  with 
nervous  and  uterine  troubles  are  principally  liable  to  suffer 
from  this  condition.  This  form  of  neuralgia  is  also  fre- 
quently found  in  diabetic  jjatients.  Sometimes  the  pa- 
tients have  the  sensation  as  if  a  foreign  body  were  in  the 
rectum. 

The  treatment  resembles  very  much  that  of  intestinal 
colic.  The  original  trouble  predisposing  to  hypogastric 
neuralgia  should  always  be  first  treated.  If  congested 
piles  are  present,  application  of  leeches  about  the  anus 
and  warm  sitz  baths  must  be  recommended.  If  the  pains 
are  violent,  suppositories  of  opium  alone  or  with  bella- 
donna should  be  used.  The  diet  should  be  a  bland  one 
and  the  bowels  should  be  caret  ally  regulated. 

'  Romberg  :  "  Lehrbuch  der  Nervenkrankheiten, "  Berlin. 


HYPERESTHESIA,  333 

Hypercesthesia,  Parcesthesia,  and  Ancesthesia  of  the 
Intestine. 

TMiile  in  tlie  normal  state  no  disagreeable  sensations  are 
manifested  during  the  act  of  intestinal  digestion  and  defe- 
cation, in  some  cases  of  neurasthenia  or  hysteria  we  mefet 
with  exceptions  to  this  rule.  Thus,  even  without  apparent 
anatomical  lesions  of  the  intestine,  there  may  be 'a  sensa- 
tion of  pressure,  fulness,  of  pinching,  of  heat  or  cold  in  the 
lower  region  of  the  abdomen  a  few  hours  after  the  inges- 
tion of  food.  The  same  sensations  may  also  occasionally 
appear  without  the  patient  having  eaten  anything,  after 
bodily  exertion  and  excitements,  especially  after  sexual 
intercourse. 

The  rectuni  and  the  anus  are  particularly  liable  to  be 
the  seat  of  abnormal  sensations.  Physiologically  a  feel- 
ing of  fulness  is  experienced  in  the  rectum  when  the  fecal 
mass  has  accumulated  in  this  locality.  In  case  of  neuras- 
thenia a  sensation  of  fulness  with  an  inclination  to  go  to 
stool  may  appear,  even  when  the  rectum  is  entirely  empty. 
Sometimes  a  feeling  of  pressure  or  weakness  in  the  anal 
region  may  be  present;  sometimes  the  patient  may  be 
tormented  by  a  constant  burning  or  itching  in  the  same 
region.  The  act  of  defecation  may  be  accompanied  by 
erections,  sometimes  by  a  feeling  of  uneasiness;  quite 
often  a  feeling  of  extreme  fatigue  after  defecation  is  ex- 
perienced. 

Ancesthesia  of  the  rectum  is  observed  in  the  same  class  of 
patients.  The  sensation  of  fulness  in  the  rectum,  which 
causes  the  desire  for  defecation,  is  then  absent;  there  is, 
therefore,  never  a  desire  for  evacuation.  In  very  pronounced 
cases  of  rectal  ano-sthesia  it  may  occur  that  even  the  pas- 
sage of  fecal  matter  through  the  anus  is  not  felt.     Such  a 


334  DISEASES  OF  THE  INTESTINES. 

liigli  degree  of  anjesthesia,  however,  is  met  with  only  in  pa- 
tients with  spina]  and  brain  troubles  and  in  very  old  and 
decrepit  individuals.  Paralysis  of  the  sphincters,  which 
has  been  described  above,  may  occasionally  accompany 
the  anaesthesia  of  the  rectum  and  thus  aggravate  the  latter. 
In  such  instances  involuntary  evacuations  of  the  bowels 
take  place  without  the  patient's  knowledge.  He  becomes 
aware  of  this  fact  only  after  his  clothes  have  been  soiled 
and  by  the  fecal  odor. 

In  the  treatment  of  these  abnormal  sensations  within  the 
intestines  attention  must  be  directed  toward  the  improve- 


FiG.  37.— Rectal  Obturator. 

ment  of  the  general  condition,  thus  raising  the  nervous 
tone  of  the  organism.  H^drotherapeutic  measures  and 
climatic  influences  are  of  the  greatest  importance.  While 
dietetic  measures  as  such  are  without  much  influence  upon 
the  nervous  disturbances  which  appear  during  the  intesti- 
nal digestion,  spicy  food  and  alcoholic  beverages  should, 
notwithstanding,  be  forbidden  and  an  essentially  vege- 
tarian regimen  recommended.  The  abnormal  sensations 
within  the  rectum  and  anus  may  be  improved  by  cooling 
rectal  douches,  by  sitz  baths,  and  also  by  rectal  galvani- 
zation. 

In  cases  of  anaesthesia  of  the  rectum  a  cleansing  enema 
in  the  morning  will  remove  the  fecal  matter  and  thus  be 
beneficial  during  the  day.     Patients  suff'ering  from  the 


MEMBRANOUS,  ENTERITIS.  335 

severer  forms  of  ansesthesia  should  wear  a  rectal  obturator 
held  in  place  by  means  of  a  T-bandage  during  the  day 
(Fig.  37). 

SECRETORY  NEUROSES  OF  THE  INTESTINES. 

Although  there  is  no  doubt  that  secretory  nerves  exist  in 
the  intestines — for  it  has  been  shown  that  the  entrance  of 
food  into  the  stomach  is  immediately  followed  by  secre- 
tion not  only  in  the  small  intestine  but  also  in  distant 
parts  of  the  large  bowel — still  we  are  yet  very  far  from  the 
knowledge  of  their  exact  location.  Nervous  diarrhoea, 
which  has  been  described  under  the  motor  neuroses,  is 
often  accomj^auied  also  by  an  increased  flow  of  intestinal 
juice.  Conditions  in  which  there  is  a  lessened  secretion 
of  intestinal  juice  are  not  yet  positively  known.  It  may 
be  that  they  exist  in  cases  of  constipation,  being  perhaps 
the  cause  of  the  latter  in  some  instances.  While,  however, 
in  the  disturbances  just  mentioned  the  increase  or  decrease 
of  intestinal  secretion  is  a  mere  hypothesis,  one  affection 
of  the  intestines  exists  in  which  increased  secretion  is  posi- 
tively found.     This  is  the  so-called  membranous  enteritis. 

Membranous  Enteritis. 

Synoyiyms.—'M.ncons  Colic;  Tubular  Diarrhoea;  Mem- 
branous Diarrhoea. 

Vejinitiou.— By  membranous  enteritis  is  understood  an 
affection  in  which  more  or  less  large  pieces  of  mucus  (usu- 
ally ribbon-like)  are  passed  periodically  with  the  fajces. 

Histot'if.— This  affection  seems  to  have  been  familiar  to 
the  medical  world  for  several  centuries.  Paulus  ^gineta, ' 
in  speaking  of  the  passage  of  the  inner  membrane  of  the 

'  Paulus  ^gineta  .  Cited  from  Da  Costa,  Americaa  Journal  of  the 
Medical  Sciences,  1871,  p.  321. 


336  DISEASES  OF  THE  INTESTINES. 

intestine,  has  certainly  dealt  with  cases  of  membranous 
enteritis,  and  erred  only  in  the  explanation  of  these 
masses. 

Sennertius  and  Morgagni '  recognized  these  membranes 
as  mucus,  which  had  been  inspissated  and  moulded  in  the 
intestine. 

Mason  Good "  was  the  first  to  describe  this  affection  un- 
der the  name  of  "tubular  diarrhoea,"  which  name  has  also 
been  accepted  by  Woodward. '  The  latter  author  adds  that 
in  case  the  membranes  in  a  given  instance  have  no  tubu- 
lar form,  the  expression  "  membranous  diarrhoea  "  is  suit- 
able. 

F.  Siredey  *  contributed  a  very  valuable  paper  in  1869 
in  reference  to  the  knowledge  of  this  affection.  He  de- 
scribed one  case  of  mucous  discharge  in  a  man  and  six 
cases  in  women,  and  arrived  at  the  conclusion  that  in  some 
instances  these  mucous  discharges  occur  in  patients  whose 
intestinal  tract  does  not  reveal  any  organic  lesion  whatever. 
For  this  reason  Siredey  regards  this  affection  as  an  in- 
testinal neurosis,  occurring  principally  in  hypochondriacs 
and  hysterics. 

Whitehead '  describes  this  affection  under  the  name  of 
"mucous  disease,"  cites  the  entire  old  literature,  and  gives 
detailed  rules  with  regard  to  treatment  and  diet.  He 
says:  "Exercise,  short  of  fatigue,  should  be  taken  daily. 

■  Sennertius  and  Morgagni :  Cited  from  J.  G.  Woodward,  "  The 
Medical  and  Surgical  History  of  the  War  of  the  Rebellion, "  1879,  part 
ii.,  vol.  i.,  p.  363. 

'  Mason  Good:  "The  Study  of  Medicine,"  cl.  1,  ord.  1,  species  7, 
vol.  i.,  Philadelphia.  1825,  p.  163. 

'  Woodward  :  Loc.  cit. 

*  Siredey,  F.  :  "  Note  pour  servir  4  1' etude  des  concretions  muqueuses 
membraniformes  de  rintestin.  "    Union  med.,  Nos.  7-9,  1869. 

'  Whitehead,  W.  :  "  Mucous  Disease. "  British  Medical  Journal, 
February  11,  1871,  p.  140. 


MEMBRANOUS  ENTERITIS.  337 

The  diet  is  perhaps  the  point  of  all  others  where  the  great- 
est mistake  is  made.  An  idea,  strongly  felt  by  the  patient, 
that  a  great  amount  of  strengthening  food  is  required, 
leads  to  the  further  exhaustion  of  an  already  enfeebled 
digestion.  Impress  upon  the  patients  the  fact  that  it  is 
the  quantity  absorbed  which  means  strength,  and  not  the 
bulk  swallowed,  and  it  is  possible  to  check  the  error  they 
are  so  anxious  to  commit.  Certain  articles  of  diet  should 
be  strictly  interdicted,  the  chief  of  which  are  the  follow- 
ing :  Liquid  food,  excepting  milk,  aggravates  in  the  major- 
ity of  cases  every  symptom ;  sugar  is  invariably  hurtful ; 
tea,  coffee,  and  alcohol — Burgundy  being  the  only  wine 
from  which  I  have  ever  derived  benefit — vegetables,  and 
fruit  also  prove  injurious." 

Cruveilhier '  and  Laboulbene  *  discuss  this  ailment  under 
the  term  "pseudo-membranous  enteritis." 

One  of  the  best  papers  upon  this  disease  was  written  by 
Da  Costa,"  who  called  it  "membranous  enteritis."  This 
author  gave  a  full  description  of  this  affection,  recognized 
its  nervous  character,  furnished  several  detailed  cases,  and 
put  particular  stress  upon  dietetic  treatment.  D^  Costa 
permits  eggs,  milk,  bread,  and  solid  food,  which  is  better 
borne  than  liquids;  tea,  coffee,  and  alcoholic  stimulants 
are  to  be  permitted  only  in  very  small  quantities.  As  re- 
gards vegetables,  we  must  observe  whether  they  pass  un- 
changed in  the  stools.  Fresh  meat  juice  is  serviceable; 
from  an  exclusive  milk  diet,  even  faithfully  carried  out,  he 
has  seen  no  good.  Furthermore,  Da  Costa  recommends 
that  great  attention  be  paid  to  the  action  of  the  skin,  and 

'  Cruveilhier:  Anat.  path,  gen.,  t.  ii. 

»  Laboulb6ne  :  "  Recherches  sur  les  affections  pseudomembraneuses. " 
1861. 

3  J.  M.  Da  Costa:  "Membranous  Enteritis."    American  Journal  of 
the  Medical  Sciences,  1871,  p.  321. 
22 


338  DISEASES  OF  THE  INTESTINES. 

believes  baths  followed  by  systematic  friction  to  be  very 
useful.  Daily  moderate  exercise  is  advocated,  particularly 
in  cool  weather,  and  if  possible  an  occasional  trip  to  the 
mountains  and  living  out  of  doors  in  the  bracing  mountain 
air.  Everything  that  can  be  done  to  invigorate  the  diges- 
tive and  nervous  systems  forms  the  essential  part  of  the 
therapeutics. 

A  few  years  later  there  appeared  an  article  by  Edwards,^ 
who  coincided  with  Da  Costa's  views  in  most  points, 
being,  however,  much  stricter  with  regard  to  diet.  He 
says:  "Easily  digested  or  "even  predigested  food  should 
be  supplied,  and  care  should  be  taken  that  undigested 
particles  of  food  are  not  irritating  the  intestinal  canal." 

Ley  den,'  in  1882,  directed  attention  to  membranous  en- 
teritis in  Germany,  where  also  very  soon  appeared  ex- 
haustive publications  on  this  subject.  Nothnagel'  sug- 
gested the  name  "colica  mucosa,"  in  order  to  show  that 
a  true  enteritis  need  not  exist  in  these  cases  and  that  the 
disease  really  is  a  mucous  colic.  Eothmann  *  was  the  first 
to  publish  a  case  of  membranous  enteritis — complicated 
with  cancer  of  the  skull — in  which  an  autopsy  was  made. 
By  means  of  Weigert's  stain,  or  rather  by  Ehrlich-Hoy- 
er's  thionin  (a  specific  stain  for  mucus),  double-stained 
specimens  could  be  obtained,  which  showed  the  presence 
of  large  quantities  of  mucus  on  the  surface  of  the  large 
bowel  in  the  glandular  tubules. 

'  Edwards  :  American  Journal  of  the  Medical  Sciences,  April,  1888, 
p.  329. 

'  E.  Leyden :  Verhandl.  d.  Vereins  f.  innere  Medicin  in  Berlin, 
Deutsche  med.  Wochenschr.,  1882,  Nos.  3.6  and  17. 

^  Nothnagel :  "  Colica  mucosa. "  BeitrUge  zur  Physiologie  und 
Pathologie  des  Darms.  "  12tes  Capitel.  1884. 

•*  Max  Rothmann  :  "  Ueber  Enteritis  membranacea."  Deutsche  med. 
Wochenschr.,  1893,  p.  999. 


MEMBRANOUS  ENTERITIS.  339 

Ewald,'  Boas/  Kittagawa/  Pariser/  and  others  have 
added  further  contributions. 

Ewald  laid  stress  on  a  ptosis  of  the  colon,  Boas  on  atony 
of  this  organ  as  important  factors  in  this  aflf action. 

Etiology. — Most  authors  agree  that  membranous  enteritis 
is  quite  a  rare  affection ;  it  occurs  much  more  frequently 
in  women  than  in  men  (children  being  only  exceptionally 
affected). 

That  the  nervous  element  (hysteria,  neurasthenia)  plays 
a  great  role  in  the  origin  of  this  trouble,  no  one  can  doubt, 
and  W.  Mendelson  *  is  right  when  he  asserts  that  neuras- 
thenia is  not  absent  in  any  of  his  cases.  Mendelson  goes 
too  far,  however,  when  he  says :  "  I  believe  that  the  reverse 
of  the  proposition  may  also  as  confidently  be  affirmed — 
namely,  that  if  neurasthenic  patients  be  closelj'  questioned, 
very  few  will  be  found  who  have  not  had  at  some  time  re- 
peated characteristic  passages  of  stringy  mucus,  associated 
with  abdominal  pains."  Membranous  enteritis  is  found 
in  nervous  individuals  (possibly  the  affection  as  such  adds 
much  to  their  neurasthenia) ;  but  only  a  small  fraction  of  the 
great  mass  of  neurasthenics  is  afflicted  with  this  ailment. 

With  regard  to  the  frequency  of  membranous  enteritis, 
1  examined  my  private  patients  of  the  year  1897  relative 
to  its  presence,  and  take  the  following  data  from  my  day- 
book. The  total  number  of  patients  was  1,315—772  men, 
643  women.     Twenty  of  these  patients  suffered  from  mem- 

'  C.  A.  Ewald:  "Membranous  or  Mucous  Enteritis."  Twentieth 
Century  Practice  of  Medicine,  vol.  ix.,  p.  265. 

*.I.  Boas:  Deutsche  raed.  Wochenschr.,  1893,  No.  41. 

3  0.  Kittagawa:  "Beitrage  zur  Kenntniss  der  Enteritis  membrana- 
cea."    Zeitschr.  f.  klin.  Medicin,  1891. 

■•Pariser:  Deutsche  med.  Wochenschr.,  1893,  No.  41. 

5  Walter  Mendelson  :  "  Mucous  Colitis  a  Functional  Neurosis. " 
Medical  Record,  January  30.  1897. 


340  DISEASES  OF  THE  INTESTINES. 

branous  enteritis — two  meu  and  eigbteen  women.  The 
frequency  of  membranous  enteritis  among  sufferers  from 
digestive  disorders  expressed  in  percentages  is,  in  men, 
0.25  per  cent;  and  in  women,  3.31  per  cent.  Among  these 
twenty  patients,  twelve  had  enteroptosis  in  a  pronounced 
degree.  Ewald  has  already  pointed  out  that  a  prolapse 
of  the  colon  is  frequently  found  in  patients  with  mem- 
branous enteritis.  My  own  observations  fully  confirm  this 
statement,  for  with  the  prolapse  of  the  stomach  descent  of 
the  colon  naturally'  must  be  presupposed.  It  aj^pears  that 
enteroptosis  certainly  creates  a  fruitful  soil  for  the  devel- 
opment of  membranous  enteritis,  although  it  does  not  di- 
rectly cause  it.  Enteroptosis  is,  as  is  well  known,  very 
-  frequent,  while  membranous  enteritis  is  rare  in  compari- 
son with  the  former.  There  must,  therefore,  be  still  other 
factors  which  are  of  importance  in  the  causation  of  mem- 
branous enteritis. 

With  reference  to  gastric  secretion  and  the  motor  func- 
tion of  the  stomach  in  this  disease,  I '  have  made  examina- 
tions on  twelve  cases  and  found  the  following  two  points 
most  conspicuous : 

1.  The  motor  function  (prochoresis)  of  the  stomach — 
judged  from  the  amount  of  contents  found  one  hour  after 
the  test  breakfast — was  increased  in  eight  cases  and  nor- 
mal in  the  four  remaining. 

2.  Five  cases  presented  a  typical  achylia  gastrica. 

Considering  the  comparative  infrequency  of  achylia  gas- 
trica, which  hardly  amounts  to  two, or  three  per  cent  of  the 
digestive  disorders,  this  large  proportion  of  achylia  in  pa- 
tients with  membranous  enteritis — namely,  five  in  twelve — 
is  certainly  noteworthy. 

'  Max  Einhorn  :  **  Membranous  Enteritis.  "  Medical  Record,  January 
28.  1899. 


MEMBRANOUS  ENTERITIS.  341 

Three  cases  of  membranous  enteritis  with  normal  acid- 
ity revealed,  besides  the  increased  prochoresis,  still  another 
feature  in  common  with  achy lia— namely,  the  extraordi- 
uarih'  small  amount  of  fluid  surrounding  the  scarcely 
changed  particles  of  roll,  one  hour  after  the  test  breakfast. 
Although  this  symptom  may  occasionally  be  met  with  in 
other  cases  than  achylia,  it  is  nevertheless,  as  a  whole, 
characteristic  of  this  afl:ection.  Therefore  we  are  justified 
in  making  the  following  statement:  In  many  cases  of  mem- 
branous enteritis  typical  achylia  is  present,  in  some  it  is 
lacking,  but  even  then  some  features  characteristic  to  achy- 
lia are  encountered.  In  membranous  enteritis  achylia  thus 
l)lays  a  great  part.  Whether  one  condition  causes  the 
other,  or  one  and  the  same  factor  (nervous  influences)  cre- 
ates both,  is  difficult  to  say.  The  latter,  however,  is  more 
plausible. 

Symptomatology. — The  disease  is  characterized  by  at- 
tacks of  rather  violent  colicky  pains  in  the  abdomen,  which 
are  followed  by  the  i^assage  of  mucous  masses  with  the 
stools.  The  mucus  may  be  voided  either  alone,  without 
any  admixture  of  fecal  matter,  or  it  forms  a  considerable 
part  of  the  evacuation.  Usually  the  attack  is  preceded  by 
a  period  of  obstinate  constipation,  and  often  followed  by 
diarrhoea  lasting  a  few  days,  and  sometimes  accompanied 
by  tenesmus.  Gastric  symptoms— as  loss  of  appetite,  fre- 
quent belching,  now  and  again  a  burning  sensation  at  the 
pit  of  the  stomach— are  generally  quite  pronounced  during 
the  attack.  Vomiting  may  occasionally  appear,  while  fever 
is,  as  a  rule,  absent.  The  attack  lasts  three  to  seven  days, 
and  then  the  pains  subside,  the  diarrhoea  ceases,  and  eu- 
phoria reappears.  More  or  less  constipation,  however, 
and  some  other  dyspeptic  as  well  as  nervous  symptoms 
persist.     These  free  intervals  last  various  periods  of  time 


342  DISEASES  OF  THE  INTESTINES. 

(four  weeks  to  five  or  six  months).  In  rare  instances  the 
mucous  discharges  may  be  present  continuously. 

With  reference  to  the  mucous  masses,  they  present  a 
grayish-white  appearance,  seldom  yellowish,  and  have 
either  a  ribbon-like  or  membranous  form;  at  times  the 
pieces  are  several  feet  Ipng ;  ordinarily,  however,  they  are 
considerably  smaller.  Complete  moulds  of  the  intestinal 
lumen  have  been  observed  by  several  authors,  and  Ley  den 
not  unjustly  has  compared  this  process  with  that  of  croup 
of  the  larynx.  As  already  stated  by  Cornil,'  the  false 
membranes  consist  of  mucus,  mixed  with  dried-up  epithe- 
lial ovoid  cells,  which  arise  from  a  mucous  metamorphosis 
of  the  cylindrical  cells  or  the  leucocytes.  Nothnagel 
and  others  have  proven  the  mucous  nature  of  these  dis- 
charges. 

As  suggested  by  Pariser,  the  mucous  nature  of  these 
masses  can  be  demonstrated  by  treating  them,  first,  with 
sublimate  alcohol,  and  then  staining  them  with  Ehrlich's 
triacid  solution.  A  green  color  appears,  which  indicates 
mucus  (fibrin  treated  in  the  same  manner  assumes  a  red 
color).  Judging  from  my  experience  it  is  unnecessary  to 
dip  these  membranes  first  into  sublimate  alcohol,  as  the 
same  result  will  follow  when  they  are  put  directly  into  the 
weak  triacid  solution.  Microscopically  this  substance  re- 
veals a  somewhat  fibrillary  nature,  and  contains  many 
shrivelled  cells,  so  called  by  Nothnagel.  Micro-organisms 
are  found  admixed,  although  they  do  not  seem  to  play  any 
important  part  in  this  affection.  In  two  of  my  cases  mi- 
croscopically single-celled  corpuscles  were  found  in  these 
masses,  having  a  distinct  nucleus  and  a  tail-like  process. 
The  accompanying  drawing  shows  these  corpuscles  (Fig. 
38).  These  are  most  probably  metamorphosed  goblet  cells. 
'  Cornil :  Cited  from  Siredey.     See  above. 


MEMBRANOUS  ENTERITIS. 


343 


Diagnosis. — The  diagnosis  of  membranous  enteritis  is, 
as  a  whole,  simple  when  the  above-mentioned  character- 
istic symptoms,  including  the  mucous  discharges,  are  pres- 
ent. It  is,  however,  necessary  to  be  careful  not  to  mis- 
take for  mucus  other  substances  admixed  in  the  faeces, 


ftO.  38.— Mlcroecoplcal  Picture  of  Mucous  Masses  Found  In  the  Evacuation  of  Mre.  L., 
Showing  Numerous  Cells  Having  a  Nucleus  and  a  Tall-like  Process. 

which  occasionally  resemble  shreds  of  mucous  membrane 
—as,  for  instance,  the  fibre  of  an  orange,  tendons,  pieces 
of  tapeworm.  A  microscopical  examination  will  guard 
against  all  such  errors. 

This  affection  will  hardly  be  confounded  with  real  intes- 
tinal catarrh,  as  it  presents  an  entirely  different  picture 
and  only  occasionally  may  have  an  abundant  secretion  of 
mucus  in  common  with  mucous  colic.    There  are,  however, 


344  DISEASES  OF  THE  INTESTINES. 

cases  of  chronic  intestinal  catarrh  which  are  complicated 
with  membranous  enteritis — that  is,  having  typical  attacks 
of  mucous  colic.  The  following  case  presents  an  instance 
of  this  kind : 

Miss  L.  N ,  twenty-eight  years  old,  had  diarrhoea 

eleven  years  ago  for  quite  a  while,  which  disappeared  after 
two  or  three  months.  The  patient  was  then  well  until 
four  years  ago,  when  she  again  began  to  be  troubled  with 
diarrhoea.  Soon  periods  of  obstinate  constipation  ap- 
peared, which  alternated  with  diarrhoea.  The  patient  re- 
ports having  occasionally  observed  mucus  in  the  passages ; 
at  times  (about  every  five  or  six  weeks)  there  appear 
abdominal  pains  for  about  one  or  two  hours,  followed  by 
an  evacuation  of  pure  mucus,  the  quantity  being  one  to  two 
tablespoonfuls.  The  appetite  was  always  good.  Now  and 
again  there  was  belching.  The  i)atient  lost  about  twenty - 
five  pounds  in  weight.  Sleep  is  undisturbed,  only  at  times 
restless  for  a  few  days.  Her  strength  greatly  failed.  Pal- 
pation of  the  abdomen  reveals  spots  sensitive  to  pres- 
sure in  the  entire  course  of  the  colon.  The  examination 
of  the  faeces  in  the  free  interval  shows  small  quantities  of 
mucus  well  mixed  with  the  fecal  matter.  The  mucous 
masses  voided  after  an  attack  of  pains  are  free  from  fecal 
matter,  appearing  grayish- white  and  staining  green  when 
treated  with  Ehrlich's  triacid  solution. 

Treatment. — Diet  plays  the  principal  part  in  the  treat- 
ment of  membranous  enteritis.  While  the  older  writers 
laid  stress  on  scanty  light  food,  it  is  now  generally  ac- 
cepted that  abundant  nutrition  is  of  the  greatest  value. 
That  a  fluid  diet  is  unsuitable,  the  older  authors  have  al- 
ready been  cognizant  of  (Da  Costa,  Whitehead,  Siredey), 
and  this  axiom  holds  good  in  its  entirety  even  to-day. 

Eecently  von  Noorden  '  advised  a  very  coarse  diet,  being 

'  C.  von  Noorden :  "  Ueber  die  Behandlung  der  Colica  mucosa. " 
Zeitschr.  f.  practiscbe  Aerzte,  1898,  No.  1. 


MEMBRANOUS  ENTERITIS.  346 

guided  by  the  idea  that  the  intestinal  tract  should  be  exer- 
cised and  strengthened  by  increased  work.  He  recom- 
mends per  day  half  a  pound  of  bread  containing  plenty  of 
chaff,  leguminous  vegetables,  garden  vegetables  rich  in 
cellulose,  fruits  with  small  pits  and  coarse  skin,  as  cur- 
rants, gooseberries,  grapes- — these  being  foods  rich  in  un- 
digestible  material,  thus  forming  much  ballast  for  the 
bowel.  Among  fifteen  patients  subjected  to  this  treatment 
b}'  von  Noorden,  seven  were  permanently  cured,  seven  im- 
proved, and  one  was  unchanged. 

This  method  has  certainly  much  in  its  favor;  it  may  be 
better,  however,  not  to  institute  this  diet  abruptly,  as  sug- 
gested by  von  Noorden,  but  rather  gradually. 

I,  for  my  part,  for  some  years  past  have  seen  to  it  that 
my  patients  partook  of  an  abundant  and  nutritious  diet, 
without,  however,  advising  substances  that  were  too  coarse. 
As  a  whole,  I  recommend  ample  food  and  try  to  keep  the 
patients  on  a  mixed  diet  containing  plenty  of  vegetables. 
In  patients  who  have  lived  on  a  strict  diet  (as  for  instance 
milk  diet  or  beef  and  hot  water),  I  arrange  the  change 
gradually.  The  principle  here  is  the  same  as  stated  by 
von  Noorden,  only  not  carried  to  such  an  extreme.  It  ap- 
pears sufficient  if  the  intestines  of  the  patient  with  mem- 
branous enteritis  are  trained  to  master  the  foods  customary 
in  healthy  persons,  and  the  accomplishment  of  this  object 
is  all  that  is  required.  If  we  subsequently  see  that  the 
organism  amply  fulfils  its  work,  a  few  less  digestible  foods 
may  then  be  added.  It  is  not  necessary  to  recommend 
these  immediately  from  the  start,  nor  are  they  important 
for  the  cure. 

With  regard  to  therapeusis,  two  phases  will  have  to  be 
considered— the  treatment  during  the  attack  and  the  treat- 
ment during  the  interval.     In  severe  attacks,  rest  in  bed. 


346  DISEASES  OP  THE  INTESTINES. 

warm  poultices  over  the  abdomen,  a  cleansing  enema  (of 
ordinary  warm  water  with  the  addition  of  some  common 
table  salt  or  essence  of  peppermint — one  teaspoonful  to  a 
quart),  and  afterward  the  administration  of  codeine  or 
opium,  with  or  without  belladonna,  are  of  value.  As  long 
as  the  pains  last  it  is  necJessary  to  give  light  food  (small 
quantities  frequently) .  In  mild  attacks  a  stay  abed  may 
not  be  requisite,  nor  the  administration  of  an  analgesic 
remedy,  and  the  diet  may  be  the  same  as  during  the  in- 
terval. 

In  the  interval  free  from  pains  the  treatment  consists  in 
a  methodical  application  of  olive-oil  enemas,  as  suggested 
by  Kussmaul  and  Fleiner. '  These  enemas  are  injected  into 
the  bowel  at  night,  at  blood  temperature,  the  quantity  being 
two  hundred  and  fiftj^  to  five  hundred  cubic  centimetres. 
The  patient  is  then  instructed  to  try  and  retain  the  oil  in 
the  bowel  during  the  night.  The  patients  seldom  assert 
that  they  are  disturbed  in  their  sleep  by  these  injections 
and  have  to  answer  nature's  call.  In  such  an  instance  the 
quantity  of  oil  may  be  reduced  to  one  hundred  and  Miy  or 
one  hundred  cubic  centimetres.  The  oil  should  be  injected 
every  night  for  three  weeks;  then  every  other  night  for 
three  weeks,  and  twice  weekly  for  four  weeks ;  finally,  once 
weekly  for  five  or  six  months.  Besides,  patients  must 
accustom  themselves  to  a  regular  morning  evacuation,  by 
promptly  visiting  the  closet  every  day  at  the  same  hour  in 
the  morning. 

Next  to  abundant  nourishment  the  methodical  oil  cure 
is  of  the  greatest  importance  in  the  treatment  of  this 
affection,  and  the  results  achieved  are,  according  to  my 
experience,  very  satisfactory.  The  administration  of  oil 
injections  in  membranous  enteritis  is  mentioned  here  and 
'  Fleiner .  Berliner  klin.  Wochensclir. ,  1893,  No.  3. 


INTESTINAL  NEURASTHENIA.  347 

there  in  recent  literature,  especially  by  Ewald,  but  its 
value  must  be  placed  much  higher  than  heretofore.  The 
oil  has  not  only  a  favorable  influence  upon  the  constipa- 
tion which  is  always  present  in  this  malady,  but  at  the 
same  time  also  effects  a  diminution  or  a  disappearance  of 
the  mucous  discharges.  How  the  oil  brings  this  about  is 
difficult  to  say.  The  favorable  effect  may  perhaps  be  ex- 
plained by  the  circumstance  that  by  means  of  the  oil  the 
intestine  is  not  left  in  an  empty  condition  during  the 
night,  and  thereby  a  spasmodic  contraction  is  avoided, 
which  must  be  regarded  as  on§  of  the  principal  factors  in 
the  formation  of  mucus. 

It  is  evident,  according  to  my  statement  with  regard  to 
the  etiology,  that  enteroptosis  and  anomalies  of  the  gas- 
tric functions  (principally  achylia)  exist  in  a  large  number 
of  these  cases.  It  will,  therefore,  be  necessary  to  bear 
these  points  in  mind  and  to  treat  the  cases  accordingly. 
The  neurotic  symptoms  present  in  these  cases  should  not 
be  neglected  in  the  general  plan  of  treatment.  We  shall 
have  to  pay  attention  to  a  regular  hygienic  mode  of  linng 
and  ample  physical  exercise.  In  suitable  cases  occasional 
hydrotherapeutic  measures  will  be  of  value.  The  tonic 
remedies,  like  iron,  arsenic,  etc.,  will  also  prove  beneficial. 

Intestinal  Neurasthenia. 

The  various  intestinal  neuroses  have  been  separately 
described.  In  practice  combinations  of  different  neuroses ' 
frequently  occur.  Following  Rosenheim  we  designate  such 
cases  as  intestinal  neurasthenia.  The  appetite  as  a  rule 
is  good  and  the  symptoms  usually  appear  during  the  pe- 
riod when  intestinal  digestion  takes  place.  The  symptoms 
generally  develop  one  to  three  hours  after  meals  and  consist 
in  a  feeling  of  pressure,  tension,  and  sometimes  of  griping 


348  DISEASES  OF  THE  INTESTINES. 

in  the  abdomen.  Occasionally  there  may  be  a  sensation 
of  nausea,  at  times  an  evacuation  of  the  bowels  accompa- 
nied with  painful  sensations  in  the  abdomen  and  in  the 
anus.  Sometimes  palpitation  of  the  heart  occurs,  some- 
times again  a  sensation  of  flashes  of  heat  or  of  cold  extend- 
ing upward.  As  a  rule,  the  patients  feel  worse  when  rest- 
ing, especially  in  the  recumbent  position,  than  when 
walking  about.  After  a  period  of  one  or  two  hours  the 
symptoms  usually  disappear,  to  return  again  later  on  after 
a  meal. 

Constipation  is  as  a  rule  associated  with  this  condition. 
The  quality  of  the  food  does  not  seem  to  exert  much 
influence  upon  the  symptoms,  although  the  latter  are 
more  marked  after  heavier  meals.  In  a  few  instances,  es- 
pecially when  the  pains  play  a  predominant  part  and  bor- 
borygmi  occur,  diarrhoea  is  encountered.  In  these  cases 
the  diarrhoea  appears  in  the  middle  of  the  night  or  toward 
early  morning,  and  disturbs  the  patient's  sleep.  It  is 
of  diagnostic  importance  that  the  j^ains  do  not  in  any  way 
depend  upon  the  quality  of  the  food.  Indigestible  foods, 
even  taken  in  considerable  quantity,  are  occasionally  well 
borne,  while  at  other  times  a  small  meal,  consisting  of  the 
lightest  food,  causes  severe  symptoms.  Intestinal  neuras- 
thenia is  sometimes  associated  with  gastric  neurasthenia 
and  completes  the  picture  of  the  other. 

In  making  the  diagnosis  of  intestinal  neurasthenia  ana- 
tomical lesions  of  the  intestines  must  first  be  excluded. 

The  treatment  consists  in  hygienic  measures  Avhich  serve 
to  tone  up  the  system,  in  ample  feeding,  and  in  the  admin- 
istration of  the  bromides,  occasionally  in  conjunction  with 
iron  and  arsenic.  With  regard  to  diet  all  foods  are  al- 
lowed excepting  indigestible  substances,  and  a  preponder- 
ance of  vegetable  food  is  to  be  recommended. 


CHAPTER  XII. 

INTESTINAL  PAEASITES. 

General  Remarks. — Most  of  the  animal  parasites  found 
in  man  inhabit  the  intestinal  canal.  Leuckart '  estimates 
the  number  of  varieties  at  about  fifty.  Not  all  parasites, 
however,  produce  morbid  conditions.  Comparatively  few 
of  them  evoke  a  pathological  state,  either  in  the  intestine 
by  their  direct  presence,  or  in  the  blood  by  the  formation 
of  toxic  products  which  are  absorbed  and  reach  the  circu- 
lation. The  intestinal  parasites  are  detected  by  rej^eat- 
edly  examining  the  stools.  They  may  be  seen  or  their 
presence  may  be  assumed  from  the  discovery  of  their  ova 
(the  latter  referring  to  the  helminths).  There  are  no  char- 
acteristic symptoms  which  would  be  encountered  only  in 
morbid  conditions  due  to  animal  parasites.  The  diagno- 
sis, therefore,  must  be  made  by  directly  discovering  them 
or  their  eggs  in  the  dejecta.  It  will  always  be  wise  to  look 
for  worms  in  cases  in  which  gastric  and  intestinal  symp- 
toms of  a  functional  character  exist,  accompanied  or  not 
by  anaemia  and  certain  neuropathic  affections.  The  intes- 
tinal parasites  are  divided  into  two  large  groups:  (1)  Pro- 
tozoa.    (2)  Vermes. 

I.  PROTOZOA. 

Amoehce. 
Besides  dysenteric  amoebse  which  have  been  described 
above,  a  similar  variety  is  occasionally  encountered  giving 
'Leuckart:  "  Die  inenschlicheu  Parasiten,"  Leipzig,  1886,  Bd.  ii. 


360  DISEASES  OF  THE  INTESTINES. 

rise  to  no  symptoms  whatever  or  sometimes  to  slight  at- 
tacks of  diarrhoea. 

Sporozoa. 

Among  the  sporozoa  coccidia  are  occasionally  found  in 
the  stools.  This  organism  is  egg-shaped,  provided  with 
a  thin  shell,  0.02  mm.  long,  and  contains  in  its  interior  a 
large  number  of  nuclei  usually  arranged  in  groups.  The 
coccidia  do  not  seem  to  have  any  pathological  bearing. 

Infusoria. 

To  these  belong  cercomonas  intestinalis,  trichomonas 
intestinalis,  and  paramaecium  coli.  All  of  them  are  found 
principally  in  conditions  in  which  diarrhoea  is  the  fore- 
most symptom. 

The  cercomonas  intestinalis  is  pear-shaped,  has  a  distinct 
nucleus  and  eight  flagellse.  The  head  portion  of  the  body 
tapers  obliquely  and  presents  a  depression  (Fig.  39).  It 
is  not  beUeved  to  have  a  direct  pathogenic  significance. 


Fig.    39.— Cercomonas    Intestinalis  (Da-       Fig.  40.— Trichomonas  Intestinalis  (Zun- 
vaine).  ker). 

It  is  assumed,  however,  that  this  micro-organism  is  liable 
to  prolong  pre-existing  catarrhal  affections  of  the  intestine. 

Trichomonas  intestinalis  xjresents  the  same  features  as 
the  cercomonas  and  can  be  distiDguished  from  the  latter  by 
its  somewhat  greater  size  and  the  row  of  fine  cilia  upon  the 
periphery  of  its  body  (Fig.  40).  In  fresh  dejecta  this  mi- 
cro-organism moves  around  very  actively.     Zunker '  found 

•Zunker:  Deutsche  Zeitschr.  f    praktische  Medicin,  1878,  No,  1. 


TAPE  WORMS. 


361 


it  principally  in  mushy  dejecta  having  a  brownish-yellow 
color  and  a  somewhat  putrid  odor. 

Paramcecium  (or  halantidium)  colt  is  egg-shaped,  0.1  mm. 
long  and  covered  with  fine  cilia,  the  latter  being  densely 
grouped  about  the  mouth,  while  but  few  of  them  surround 
the  anus.  In  the  interior  of  this  or- 
ganism are  found  a  nucleus  and  two 
contractible  vesicles,  besides  fat  droj)- 
lets,  starchy  particles,  etc.  (Fig.  41). 
The  balantidium  coli  was  first  de- 
scribed by  Malmsten '  in  1857.  In 
the  fresh  stools  the  balantidium  moves 
about  very  rapidly,  but  it  dies  as  early 
as  one-half  an  hour  to  two  hours  after 
the  dejecta  have  been  passed.  Like 
the  cercomonas,  the  paramgecium  coli 
is  believed  to  keep  up  conditions  of 
diarrhoea. 

The  treatment  directed  against  these 
infusoria  consists  in  intestinal  irriga- 
tion with  water}'  solutions  of  tannic  acid,  boracic  acid, 
thymol,  or  quinine. 

II.  VERMES. 
Cesiodes  (Tape  Worms). 

General  Remarks. — In  describing  the  disorders  caused 
h\  tapeworms  it  is  best  to  include  the  taenia  solium,  taenia 
mediocanellata,  and  bothriocephalus  latus. 

The  symptoms  produced  by  these  three  diflferent  entozoa 
are  almost  identical.  In  some  instances  the  tapeworm  is 
domiciled  in  the  intestine  for  a  long  period  of  time  with- 
out manifesting  any  symptoms.  The  host  may  enjoy  \^ev- 
'  Malmsten:  Vircliows  Arcliiv,  Btl.  xii. 


F 1 6 .  41.  —  Balantidium 
CoU  (Glaus),  a.  Mouth ; 
h.  nucleus ;  c.  a  granule 
of  starrb  which  has 
been  Ingested ;  d,  a  for- 
eign body  in  the  procet» 
of  being  expelled. 
Highly  magnified. 


352  DISEASES  OP  THE  INTESTINES. 

feet  health  and  only  after  noticing  segments  of  taenia  in  the 
dejecta  does  he  become  conscious  of  his  uninvited  guest. 
In  other  instances  the  worm  produces  intestinal  as  well  as 
general  disturbances.  A  feeling  of  pressure  at  the  pit  of 
the  stomach  and  pains  at  different  points  of  the  abdomen 
may  be  jjresent.  Bulimia  is  frequently  encountered. 
Anorexia  and  anorexia  alternating  with  bulimia  are  also 
occasionally  observed.  Nausea,  even  vomiting,  may  be 
present,  especially  in  the  morning.  The  bowels  are  usu- 
ally constipated.  In  a  few  instances,  however,  there  is 
persistent  diarrhoea. 

Besides  these  gastro-intestinal  symptoms  there  may  be 
present  various  disturbances  of  the  nervous  system  or  of 
the  blood;  dizziness,  headache,  fainting  spells,  convul- 
sions, epilepsy,  various  forms  of  parsesthesia  of  the  ex- 
tremities. Some  patients,  again,  look  very  bad  and  be- 
come emaciated,  notwithstanding  that  they  take  sufficient 
quantities  of  food.  The  ansemic  condition  is  occasionally 
very  marked.  The  patient  feels  extremely  weak,  suffers 
from  palpitation  of  the  heart,  is  hardly  able  to  walk,  and 
is  subject  to  fainting  spells.  In  this  serious  form  of  anae- 
mia oedema  of  the  feet  and  eyelids  may  exist  as  well  as 
hemorrhages  from  the  mucous  membranes.  The  micro- 
scopical examination  of  the  blood  in  these  instances  reveals 
poikilocytosis  and  also  nucleated  red  blood  corpuscles, 
thus  demonstrating  the  existence  of  a  progressive  per- 
nicious anaemia.  The  grave  condition  just  described  has 
been  observed  only  in  the  presence  of  bothriocephalus 
latus  but  not  of  the  other  varieties  of  tapeworms. 

The  proof  that  the  symptoms  described  are  produced 
by  the  tapeworm  is  found  in  the  circumstance  that  they 
disappear  entirely  after  the  removal  of  the  parasite. 

None  of  the  above  symptoms,  however,  permits  the  diag- 


TAPE  WORMS.  363 

nosis  of  tapeworm,  for  they  are  found  also  when  it  is  not 
present.  The  diagnosis  can  be  made  only  by  the  discov- 
ery of  either  segments  of  the  parasite  or  their  eggs  in  the 
stools. 

The  tapeworm  has  a  head  or  scolex,  which  may  remain 
alive  for  years, — even  when  separated  from  the  other  part 
of  the  body, — an  oblong  neck  and  detachable  segments 
(proglottides).  The  latter  vary  in  size  and  in  configura- 
tion the  farther  away  from  the  head  they  are  situated. 
They  possess  the  power  of  moving.  The  tapeworm  is  a 
fiat  worm  devoid  of  mouth  or  intestine.  It  grows  by  alter- 
nate generation  through  the  germination  of  a  pear-shaped 
primary  host  (head)  and  remains  united  with  the  latter  for 
a  considerable  time  as  a  long  band-shaped  colony.  Each 
member  of  the  colony  forms  a  sexually  active  individual. 
The  proglottides  increase  in  size  the  more  distant  they  are 
from  the  head.  The  tapeworm  is  an  hermaphrodite.  It  is 
provided  on  its  head  with  four  sucking  discs,  by  means  of 
which  it  is  enabled  to  attach  itself  to  the  intestinal  mu- 
cosa. It  derives  its  nourishment  by  means  of  pores  from 
the  intestinal  chyme.  The  older  proglottides  contain  a 
large  number  of  fructified  eggs.  The  la^tter  are  off  and  on 
emptied  into  the  intestinal  canal  and  then  appear  in  the 
dejecta. 

The  ovum  contains  an  embryo  which  requires  for  its  de- 
velopment an  intermediary  host.  After  reaching  the  stom- 
ach of  the  intermediary  host  the  envelope  of  the  ovum  is 
dissolved  by  the  gastric  juice.  The  embryo  is  now  set 
free  and  finds  its  way  either  by  the  lymphatics  or  by  the 
blood-vessels  to  some  place  (usually  the  muscles)  where  it 
settles.  Here  it  surrounds  itself  with  a  sac,  which  later 
on  may  become  surrounded  with  a  calcareous  deposit.     In 

this  condition  the  embryo  is  called  cysticercus  or  measle. 
23 


354 


DISEASES  OF  THE  INTESTINES. 


When  the  measle  again  reaches  the  stomach  of  a  new  host 
it  then  opens  and  its  scolex  advances  into  the  small  in- 
testine, where  it  develops  into  a  full-grown  taenia. 

Tcenia  Solium. — Taenia  solium,  or  the  armed  tapeworm, 
when  fuUj  developed,  is  from  two  to  three  metres  long. 
Its  head  is  of  pinhead  size  and  spherical  in  shape.  It  has 
four  cuplike  suckers,  in  the  middle  of  which  is  situated  the 
rostellum,  the  latter  being  surrounded  with  a  large  number 
of  hooks  (Fig.  42).  These  are  arranged  in  two  rows  and 
number  from  twenty-four  to  twenty-six.  Succeeding  the 
head  is  a  filiform  neck,  almost  an  inch  long.     Commencing 

at  a  certain  distance  from 
the  head  the  body  is  di- 
vided into  segments. 
The  mature  proglottides 


Pig.  42.— Head  of  Taenia  Solium  with  Pro- 
truding Rostellum.  MagnlQed  50  diameters. 
(Zlegler.) 


Fig.  43.— Half  Developed  and  Fully 
Matured  Segments.  Natural  size. 
(Leuckart.) 


are  1  to  1.5  cm.  long  and  6  mm.  wide.  The  genital  open- 
ing is  situated  at  the  side  near  the  j^osterior  border  of  the 
tjegment  (Fig.  43).  The  uterus  forms  a  straight  median 
tube,  giving  off  at  right  angles  five  to  seven  branches  on 


TAENIA  SAGINATA.  365 

each  side.  These  branches  are  undivided  at  first,  but  to- 
ward the  periphery  ramify  in  the  form  of  a  tuft  (Fig.  44). 
The  eggs  are  round  and  provided  with  a  thick  shell. 

TsBuia  solium   inhabits  the  small  intestine  of  human 
beings.     The  further  development  of    the    embryo  into 


A 
Fig.  44,— Taenia  Solium.    Showing  two  proglottides.    A,  A,  pores.    (Huber.) 

measles  occurs  in  the  intermediary  host,  the  pig,  in  which 
condition  they  reach  the  human  system  and  are  trans- 
formed into  mature  tsenias.  Earely  the  measles  (cysto- 
cercus  cellulosse)  are  found  in  men,  in  which  instance  they 
occur  in  various  organs,  brain,  eye,  skin,  etc.  The  grav- 
ity of  the  disease  which  they  produce  depends  upon  the 
importance  of  the  organ  thej'  involve. 

Tcenia  Saginata  or  3Iediocanellata. — This  tapeworm  is 
the  one  most  frequently  observed  in  America  as  well  as 
abroad.  The  taenia  saginata  is  much  longer,  thicker,  and 
wider  than  taenia  solium.  The  head  is  2.5  mm.  large,  has 
four  large  sucking-discs  but  no  rostellum,  and  is  often 
pigmented  (Fig.  45).  The  length  of  the  worm  is  4  to  5 
metres,  the  proglottides  are  unusually  thick,  the  widest 
being  in  the  middle.  The  mature  segments  occasionally 
attain  a  length  of  2.5  cm.  The  uterus  lies  in  the  middle 
of  the  segment  and  gives  off  numerous  branches  on  both 
sides  (about  twenty  on  each  side  (Fig.  46).  The  genital 
opening  is  situated  on  the  side  below  the  middle.     The 


356 


DISEASES  OF  THE  INTESTINES. 


eggs  have  an  elliptical  shape,  a  brownish  color,  and  a  con- 
tour exhibiting  radiating  streaks. 

The  taenia  sagiuata  inhabits  the  small  intestine  of  man. 
Its  measles  occur  in  beef,  as  has  been  demonstrated  by 


P 


3 

a 

li 
si 


■a 
e4  a 
a  * 


Huber '  and  Leuckart.    These  measles  are  usually  smaller 

than  those  of  tsBuia  solium.     Human  beings  acquire  this 

'Huber:   "Twentieth  Century  Practice  of  Medicine,"  vol.   viii.,  p. 
570. 


BOTHRIOCEPHALUS  LATUS.  367 

taenia  by  tlie  consumption  of  raw  beef.     The  measles  have 
not  as  yet  been  found  in  man. 

■  Bothriocephalus  Latus,  Tcenia  Lata  or  Pig  Head. — This 
tapeworm  is  the  longest.  It  measures  from  five  to  eight 
metres.  The  head  is  elongated,  of  almond  shape,  being 
about  2.5  mm.  in  length  (Fig.  47).  It  has  two  lengthy 
big  grooves  on  its  flat  surface  (Fig.  48).  The  neck  is  nar- 
row, about  2  cm.  long.  The  body  is  thin  and  flat  like 
a  ribbon,  excepting  the  central  part  of  the  segments  which 


Fig.  46.— The  Uterus  and  its  Branches  in  a  Segment  of  Taenia  Saginata.    Enlarged  3 
diameters.    CHuber.) 

project  somewhat  outward.  The  genital  openings  are  on 
the  flat  surface  in  the  middle,  the  female  very  close  to  the 
male.  The  uterus  has  a  special  opening  and  four  to  six 
visible  uterine  convolutions  on  each  side,  which  look  al- 
most like  a  rosette.  The  eggs  are  oval,  round,  with  a  thin 
membrane  and  a  lid  (Fig.  49).  They  measure  0.07  mm. 
in  length  and  0.04  in  width. 

The  measle  of  bothriocephalus  latus  occurs  principally 
in  fish,  especially  in  pike,  turbot,  i^erch,  and  trout. 

The  taenia  lata  lives  in  the  small  intestine  of  man,  but 
is  also,  though  rarely,  found  in  dogs.  In  the  northeast- 
ern part  of  Europe,  Holland,  Switzerland,  and  Japan  this 
tapeworm  is  very  prevalent.     In  America  it  occurs  but  in- 


358 


DISEASES  OF  THE  INTESTINES. 


frequently.     As  stated  above,  among  the  symptoms  pro- 
duced by  botbrioceplialus  anaemia  is  often  observed. 

Aside  from  the  three  tape- 
worms just  described  there  exist 
a  few  more  varieties  which  are 
only  rarely  met  in  human 
beings.     They  are : 

(1)  Tcenia  Nana.  —This  is  the 
smallest  tapeworm  found  in 
man.  It  measures  10  to  15  mm. 
in  length  and  may  have  one  hun- 
dred and  ninety  segments.  The 
head  has  four  sucking  -  discs, 
a  rostellum,  twenty  -  four  to 
twenty-eight  hooklets  in  a  sin- 
gle row.  The  proglottides  are 
short  and  broad;  the  genital 
openings  are  on  one  side. 
This  tapeworm  has  been  ob- 
served principally  in  Egyj^t  and 
Italy  in  children.  It  usually 
occurs  in  large  numbers  in  the 
small  intestine,  from  forty  to 
even  five  thousand.  The  symp- 
toms produced  by  this  tapeworm 
are  mostly  nervous  disturbances, 
fainting  spells,  occasionally 
even  epilepsj'. 

(2)  Ta'uia  Cncumerhia. — 
This  small  cucumber-shaped 
tapeworm  occurs  frequently  in 

the  intestine  of  the  dog,  but  has  also  been  found,  although 
rarely,  in  small  children.     The  tapeworm  is  10  to  40  cm. 


Fig.   47.  —  Bothiiocephalus  Latus 
Natural  size.    (Leuckart.) 


TAPE  WORMS. 


359 


long  aud  about  3  mm.  wide.     The  measle  of  this  taenia 
inhabits  the  flea. 

(3)  Tcenia  Flavo-Punctata  or  Tcenia  Diminuta. — This 
parasite  is  2  to  6  cm.  long  and  3.5  mm.  wide.  Its  head 
is  very  small,  club-shaped,  and  provided  with  sucking- 
discs.     The  measle  infests  the  caterpillar  and  cocoon  of 


Fig.  48.  Fig.  49. 

Fig.  48.— Head  of  Botliriocephalus  I^tus.    Matrnlfled.    (Heller.) 
Fig.  49.— Eggs  of  Bothrlocephalus.    (Krabbe.) 

asopia  famialis  and  in  the  coleoptera  axispinosa.  This 
tapeworm  has  been  observed  in  man  only  a  few  times. 

(4)  Bothriocephalus  Cordaius.  — This  tapeworm  resembles 
in  all  particulars  the  bothriocephalus  latus  except  that  it 
is  much  shorter  and  that  the  head  merges  into  the  proglot- 
tides directly  without  an  intermediary  neck.  It  occurs  in 
the  intestine  of  men  and  dogs  in  Greenland. 

The  list  of  the  tapeworms  enumerated  above  is  not  com- 
plete, for  there  exist  the  taenia  madagascariensis,  bothrio- 
cephalus liguloides,  and  others,  but  as  'these  do  not  occur 
in  Europe  or  America  a  description  of  them  does  not  ap- 
pear to  be  of  practical  interest. 

Treatment. — Prophylaxis.  In  order  to  escape  infection 
with  tapeworm  it  is  necessary  to  abstain  from  raw  or  me- 
dium done  meats,  including  fish.     The  sanitary  inspection 


360  DISEASES  OF  THE  INTESTINES. 

of  the  meat*  is  no  absolute  guarantee  that  it  is  free  of 
measles.  Thorough  boiling  or  broiling  of  the  meat  de- 
stroys the  cysticerci  and  thus  the  danger  is  avoided.  In 
order  to  diminish  the  spread  of  tapeworm  it  is  advisable 
to  free  the  patient  of  the  worms  and  thoroughly  to  destroy 
them  as  soon  as  possible  after  they  have  left  the  intestine. 
Whoever  examines  the  proglottides  or  the  ova  should  care- 
fully wash  and  disinfect  his  hands  immediately  afterward 
in  order  to  avoid  auto-infection. 

The  direct  treatment  of  the  tapeworm  consists  in  meas- 
ures to  expel  it  from  the  intestinal  canal.  This  is  accom- 
plished by  emptying  the  bowels  previously  and  giving  a 
vermifuge  afterward.  The  treatment  is  carried  out  in  the 
following  way :  For  about  two  days  before  giving  the  ver- 
mifuge the  patient  is  kept  on  a  scanty  diet,  consisting  of 
some  milk,  meat  and  broth,  very  little  bread  or  none  at 
all.  A  laxative  (calomel  eight  to  ten  grains  or  castor  oil 
one  tablespoonful)  is  given  once  a  day.  On  the  evening 
preceding  the  administration  of  the  vermifuge  the  patient 
should  have  no  supper  or  should  take  only  salt  herrings 
with  onions.  On  the  following  morning  a  cup  of  coffee  or 
tea  is  given.  Half  an  hour  to  one  hour  later  the  vermifuge 
is  administered.  Among  the  drugs  for  the  removal  of  the 
tapeworms  the  following  are  the  most  efficient : 

Male-fern  extract  is  given  in  doses  of  6  to  10  gm.  (  3  iss.- 
iiss.),  as  for  instance: 

^  Extr.  fllicis  mar.  aether 8.0  (  3  ij.) 

Syr.  simpl 40.0  ( |  H) 

S.  To  be  taken  iu  ten  minutes. 

The  dose  of  male-fern  should  never  be  very  high  and 
should  not  exceed  10  gm.  (  3  iiss.),  as  symptoms  of  intoxi- 
cation have  frequently  been  observed. 

Pomegranate    root  is  also  au  efficient  remedj',    espe- 


TAPE  WORMS.  361 

cially  if  it  is  fresh.  It  may  be  given  in  an  infusion  of  the 
bark,  three  ounces  of  which  are  macerated  in  ten  ounces  of 
water  and  then  reduced  to  one-haK  by  evaporation.  The 
entire  quantity  is  then  taken  within  half  an  hour. 

Pelletierine,  the  active  principle  of  pomegranate  root, 
may  also  be  used  in  doses  of  five  to  eight  grains. 

Flores  koosso,  about  20  to  30  gm.  (  3  v.  to  3  i.)  of  the 
blossoms  are  thoroughly  mixed  in  sugar  water  or  lemon- 
ade and  should  be  taken  within  one-half  or  one  hour,  or — 

IJ  Flores  koosso, 

Mellis  despumati aa  3  v.  (20  gm.) 

Fiat  electuarium.     S.  To  be  taken  in  two  portions. 

Kamala  may  also  be  employed  in  doses  of  10  gm. 
(  3  iiss.)  mixed  in  aqua  foeniculi  or  in  wine  and  taken  in 
the  same  way.^ 

Turpentine  30  to  60  gm.  (  3  i,-ii.)  may  be  given  in  cap- 
sules. After  this  medicament  one  or  two  glassfuls  of  milk 
should  be  taken. 

Pumpkin  seeds  (semina  cucurbitse)  may  be  administered 
in  doses  of  120  gm.  (  3  iv.),  thoroughly  mixed  with  the 
same  amount  of  grape  sugar. 

Cocoanut  has  also  been  recommended  for  this  purpose. 
The  milk  and  albumin  of  an  entire  nut  should  be  consumed 
within  one  hour. 

Naphthalin  in  doses  of  0.6  to  2.0  gm.  (gr.  x.-xxx.)  may 
be  given  in  capsules. 

Salol  3  gm.  (gr.  xlv.)  in  capsules  may  also  be  advanta- 
geously employed. 

One  or  two  hours  after  the  administration  of  the  vermi- 
fuge a  cathartic  should  be  given,  usually  about  two  table- 
spoonfuls  of  castor  oil,  or  citrMe  of  magnesia  one  to  two 
teaspoonfuls.     The   resulting  evacuation    must    be  thor- 


362  DISEASES  OF  THE  INTESTINES. 

oughly  examined  and  the  tapeworm  looked  for,  especially 
its  head. 

Children  require  a  correspondingly  smaller  dose  of  the 
above  remedies,  according  to  their  age.  Patients  who  are 
debilitated,  or  have  intestinal  disorders  or  organic  lesions 
of  the  digestive  tract,  should  not  be  subjected  to  this  treat- 
ment, nor  should  it  be  employed  shortly  after  typhoid 
fever  or  other  grave  diseases.  In  these  conditions  it  is 
necessary  to  x>ostpone  the  treatment  until  a  more  oppor- 
tune time. 

Trematodes  {Fluke  Worms). 

The  trematodes  are  solid  worms  of  a  tongue  or  leaf 
shape.     They  possess  a  clinging  apparatus  in  the  form  of 


Fie.  GOl— Distoma  Hepaticum.  wltti  Male  and  Female  Sexual  Apparatus.    CLeucltart.) 
Ma^fled  2H  diameters. 

oral  and  ventral  sucking-cui^s  varying  in  number.  Some- 
times they  are  also  provided  with  hook  or  clasp  like  pro- 
jections for  this  purpose.  The  intestinal  canal  is  without 
any  anus  and  is  split  like  a  fork  nearly  throughout  its 
extent.  The  fluke  worms  are  mgstly  hermaphroditic.  To 
these  belong : 

Distoma  Hejmticum  or  Liver  Fluke. — This  parasite  has 
a  leaf  shape,  is  22  mm.  long  and  12  ram.  wide.  The  ceph- 
alic end  projects  like  a  beak  and  bears  a  small  cuplike 


DISTOMA  LA^XEOLATUM. 


363 


sucker,  in  which  the  mouth  is  located.  Close  behind  this 
on  the  ventral  surface  is  a  second  suction  cup  and  between 
the  two  lies  the  sexual  orifice.     The  uterus  consists  of  a 


Fig.  51.— Eggs  of  Dlstoma  Hepaticum.    (Leuckart.)    Magnified  300  dlameteis. 

convoluted  bulb-shaped  bag.  situated  behind  the  posterior 
sucker.  On  each  side  of  the  body  lie  the  ovisacs  and  be- 
tween them  the  much  branched  testicular  canals  (see  Fig. 
60).  The  eggs  are  oval,  0.13  mm.  long  and  0.08  mm. 
wide.  They  have  a  brownish  color  and  are  provided  with 
a  lid  (Fig.  51). 

The  liver  fluke  is  rare  in  man,  though  frequently  found 
in  ruminating  animals.  It  inhabits  the  biliary  ducts  and 
is  occasionally  found  in  the  intestine  and  in  the  inferior 
vena  cava.  The  symptoms  which  it  produces  are  varied: 
jaundice,  enlargement  of  the  liver,  diarrhoea,  hemorrhages. 


Fig.  52.— Distoma  Lanceolatum  with  its  Inner  Organs.     (Leuckart.)     Magnified  10 

diameters. 

Most  probably  the  liver  fluke  reaches  the  intestinal  canal 
b^'  means  of  impure  water  or  vegetables. 

Distoma  lanceolatum  is  8  to  9  mm.  long  and  2  to  2.5  mm. 
wide.  It  has  a  lancet  shape  and  the  head  portion  is  not 
specially  marked  ofi"  from  the  body  (Fig.  52).     The  eggs 


364 


DISEASES  OP  THE  INTESTINES. 


are  considerably  smaller  than  those  of  distoma  hepaticum, 
being  only  0.04  mm.  long  (Fig.  53).  With  regard  to  itq 
occurrence  and  symptoms  it  resembles  the  liver  fluke. 

Diatoma    hcematobium  or  BUliarzki    hcematobia    is    fre- 
quently found  in  hot  climates,  especially  in  Egypt.     In 


Fig.  53.— Egg  of  Distoma  Lanceolatum  Shortly  After  the  Formation  of  a  Shell.    (Leuck- 
art.)    Maj?nlfled  400  diameters. 


the  United  States  and  in  Europe  it  is  very  rarely  found. 
This  parasite  has  separate  sexes.  The  male  is  from  12 
to  14  mm.  long.  Its  body  is  smooth,  but  in  its  posterior 
portion  rolled  up  into  a  tube,  which  serves  for  the  recep- 
tion of  the  female  (canalis  gynsecophorus)  (Figs.  54  and 
55).     The  female  is  from  16  to  19  mm.  long  and  almost 


Fig.  54. 


Fig.  55. 


Fig.  54.— Distoma  Haematobium.    (Leuckart.)    Male  and  Jemale,  the  latter  in  the  ca- 
nalis gynaecophorus  of  the  former.    Magnifled  10  diameters. 
Fig.  55.— Eggs  of  Distoma  Haematobium.    (Leuckart.)    a.  Egg  with  terminal  spine;  b. 
egg  with  lateral  spine.    MagniQed  150  diameters. 

cylindrical.     The  sexual  opening  lies  in  both  sexes  close 
behind  the  ventral  sucker.     The    distoma    haematobium 


ROUND  WORMS.  366 

•  finds  its  way  into  the  intestinal  canal  of  man  and  then 
reaches  the  portal  circulation,  where  it  develops.  In  the 
intestinal  canal  it  has  been  encountered  ver^-  rarely,  in 
which  case  ulcerations  of  the  intestinal  mucosa  were  pres- 
ent. It  fre(iuently  causes  hsematuria  and  great  cachexia, 
terminating  fatally  in  some  instances. 

As  regards  treatment,  the  removal  of  these  fluke  worms 
must  be  undertaken  in  identically  the  same  manner  as  that 
of  the  tapeworms  described  above. 

Nematodes  {Round  Worms). 

The  round  worms  which  occur  as  parasites  have  a  slen- 
der, cylindrical,  sometimes  filiform  body,  with  neither 
segments  nor  ai)pendages.  The  integument  is  thick  and 
elastic.  The  oral  opening  is  at  one  extremity  and  provided 
with  either  soft  or  hornlike  lii)s.  The  alimentary  canal 
extends  throughout  the  entire  body  cavity,  terminating  in 
an  opening  upon  the  ventral  side  at  a  short  distance  from 
the  posterior  extremity.  The  sexual  organs  and  their  ori- 
fices lie  on  the  ventral  surface.  The  female  aperture  is 
located  at  about  the  middle  of  the  body ;  in  the  male  the 
sexual  orifice  is  situated  close  to  the  anus.  The  males 
are  usually  much  smaller  than  the  females. 

Ascaris  Lumbricoides  (Common  Spool  or  Bound  Worm). — 
This  worm  is  one  of  the  most  frequently  observed  para- 
sites in  man.  The  round  worm  has  a  light  brown  or  red- 
dish color  and  a  cylindrical  shape.  The  male  is  20  cm. 
and  the  female  30  cm.  long.  The  posterior  extremity  of 
the  male  is  bent  in  the  form  of  a  hook  and  provided  with 
two  spicules  or  chitinous  processes.  The  mouth  is  sur- 
rounded by  three  muscular  lips  provided  with  very  fine 
teeth.  The  sexual  opening  of  the  female  lies  anterior  to 
the  middle  of  the  body  (Fig.  5G).     The  eggs  when  ripe 


DISEASES  OF  THE  INTESTINES. 


Fig.  i56.— Ascarls  Lumbrlcoldes.  (Perls.) 
A,  Female:  B,  male.  (Natural  size.) 
At  a  Is  the  female  sexual  oriflce ;  c, 
the  two  spicules  of  the  male ;  h,  head 
extremity  (magnified)  of  the  worm, 
with  the  three  lips. 


have  a  double  shell  and 
around  this  is  an  albumi- 
nous envelope  which  is  ir- 
regularly shaped,  and 
studded  with  excreseencjes 
(Fig.  67).  The  long  di- 
ameter of  the  egg  is  about 
0.05  mm. 

The  round  worm  pos- 
sesses a  strong  odoriferous 
principle  which  is  very 
perceptible  even  after  the 
worm  has  been  carefuU}' 
washed.  According  t  o 
Huber, '  this  substance 
may  occasion  urticaria  in 
persons  predisposed  to  this 
eruption.  It  is  not  im- 
probable that  certain  of 
the  symptoms  of  ascariasis 
are  due  to  the  action  of 
the  same  element. 

The  principal  habitat  of 
ascaris  lumbricoides  is  the 
small  intestine  of  man.  It 
develops  here  often  in  large 
numbers,  fifty  to  one  hun- 
dred and  more  occurring 
together.  The  mode  of 
transmission,  according  to 

'  Huber:  "Twentieth  Century 
Practice  of  Medicine,  ^  vol.  viii., 
p.  583. 


ASCARIS  LUMBRIC0IDE8. 


367 


Leuckart,  Grassi,'  and  Lutz,'  is  by  ingestioa  of  the  eggs  of 
the  ascaris,  there  being  no  intermediate  host.  The  full 
development  of  the  round  Avorm  from  the  egg  to  its  period 
of  sexual  maturity  requires  ten  to  twelve  weeks.  Infection 
usually  takes  place  by  eggs  existing  in  the  soil  near  dwell- 
ing-places, in  the  drinking-water,  and 
also  in  some  foods,  principally  salads 
and  fruits.  Ascaris  lumbricoides  is 
most  frequently  found  in  children  three 
to  twelve  years  old,  the  poorer  classes 
showing  a  larger  percentage  than  the 
well-to-do.  In  grown  persons  the  worm 
is  not  so  frequent.  The  female  sex  is 
more  frequently  infected  than  the 
male. 

The  diognosis  of  ascariasis   is  made 
by  the  detection  of  the  worm  in  the  fecal  matter,  or  of  its 
eggs,  which  are  easily  recognized. 

Symptoms. — Ascariasis  may  exist  without  giving  rise  to 
any  symptoms  whatever.  Occasionally,  however,  there  are 
various  disturbances :  anorexia,  nausea,  irregularity  of  the 
bowel,  meteorism,  an  irregular  pulse;  in  children  black 
rings  around  the  eyes,  much  nervousness,  even  convul- 
sions. In  rare  instances  progressive  anaemia  has  been  ob- 
served (Leichtenstern).  Anatomically  hyperemia  of  the 
intestinal  wall  has  been  frequently  found,  erosions  are  rare. 
Itching  of  the  nose  is  often  present  in  ascariasis  and  may 
be  due  to  the  odoriferous  principle. 

The  round-worm  is  liable  to  wander  and  may  then  give 
rise  to  severe  complications.     In  several  instances  it  has 


Fig.  57.— Eg?  of  As- 
caris Lumbricoides 
(Leuckart)  with  Shell 
and  Albuminous  En- 
velope. Magnified 
300  diameters. 


'  Grassi :  Centralbl.  f .  Bacteriologie  und  Parasitenkunde,  1887. 
*  xVdolf  Lutz :    •'  Klinisches  ilber  Parasiten  des  Menschen  und  der 
Haustbieie."    Ceutralbl.  f.  Bacteriologie.  1889. 


368  DISEASES  OF  THE  INTESTINES. 

been  found  in  the  bile  duct,  in  the  gall  bladder,  and  even 
in  the  liver,  producing  abscesses  and  even  a  fatal  issue. 
The  worm  occasionally  migrates  into  the  stomach  and  pro- 
duces pain  and  often  vomiting.  In  the  latter  act  it  is  often 
expelled  from  the  mouth.  Occasionally  it  ascends  the 
oesophagus  and  enters  the  larynx,  causing  asphyxia,  and, 
in  rare  instances,  even  death.  It  has  also  been  found  in 
hernial  sacs  and  in  the  peritoneal  cavity,  but  it  is  gen- 
erally believed  that  it  cannot  penetrate  through  the 
healthy  intestinal  wall.  Obstruction  of  the  bowels  by  a 
conglomeration  of  ascarides  has  also  been  thought  pos- 
sible ;  its  real  occurrence,  however,  is  denied  by  Leichten- 
stern. ' 

Prophylaxis  requires  total  destruction  of  all  the  eggs  of 
the  ascaris  passed  with  the  fecal  matter  of  the  patient. 
The  grounds  near  dwellings  should  be  kept  perfectly  clean 
and  the  hands  should  be  frequently  washed.  All  foods 
should  be  protected  against  a  possible  infection. 

Treatment. — The  treatment  consists  in  freeing  the  pa- 
tient from  the  worms.  This  is  done  in  a  similar  manner 
as  in  the  case  of  tapeworms.  The  intestinal  tract  is  kept 
partially  empty  for  a  day  or  two  before  the  administration  of 
the  anthelmintic.  The  most  efficient  remedj'  for  this  pur- 
pose is  santonin,  which  is  given  in  a  dose  of  0.02  to  0.06 
gm.  (gr.  ^i.)  twice  or  four  times  a  day.  Then  a  purgative 
remedy  is  given.  Some  combine  the  santonin  witli  the 
purgative  and  give  them  together.  Thus  santonin  0.2  (gr. 
iiiss.),  castor  oil  60  gm.  (  3  ii.),  twice  or  three  times  daily 
one  teaspoonful  for  small  children,  a  dessertspoonful  for 
larger  children,  and  one  tablespoonful  for  grown  people. 

'  Leichtenstern :  "  Verengerungen,  Verschliessungen  und  Lageveran- 
derungen  des  Darms."  von  Ziemssen's  HaiK'.l)uch  der  spec.  Path,  iind 
Tliorapie,  Bd.  vii.,  Abth.  2. 


OXYURIS  VERMICULARI8.  369 

The  santonin  may  also  be  given  iu  combination  with  cal- 
omel; thus — 

ij  Calomel 0.05  to  0.1  (gr.  i.-ij.) 

Santonin 0.02  (gr.  i) 

T.  d.  No.  ix.     S.  One  powder  three  times  daily. 

Flores  cinse,  the  plant  from  which  santonin  is  obtained, 
may  also  be  administered  in  doses  of  0.5  to  2  gm.  as 
powders  or  as  an  electuary,  with  the  addition  of  jalap,  0.1 
to  0.2  gm. 

Chenopodium  or  wormseed  is  also  a  popular  remedy, 
the  powdered  seeds  being  given  in  doses  of  1  to  2  gm. 
(gr.  xv.-xxx.),  or  the  volatile  oil  in  five  to  ten  drop  doses. 
Thymol  has  also  been  recommended  in  doses  of  0.5  to 
2  gm.  (gr.  vii.-xxx. )  in  twenty -four  hours.  It  maj^  be  given 
in  gelatin  capsules.  Irrigation  of  the  bowels  with  water 
to  which  three  to  five  drops  of  benzene  have  been  added 
has  likewise  been  suggested,  but  does  not  appear  as  bene- 
ficial as  santonin. 

Ascaris  Mystax.  — A  round- worm  resembling  ascaris  lum- 
bricoides  but  much  smaller  and  somewhat  thinner.  This 
parasite  frequently  occurs  in  animals,  principally  in  cats, 
but  has  been  discovered  very  rarely  in  man.  No  symp- 
toms whatever  have  been  observed. 

Oxyurvi  Vermicularis,  Aivltail,  Seat  or  Pin  Woim,  Blag- 
got  or  Thread  Worm. — This  parasite  is  white  and  filiform, 
4  to  12  mm.  long  and  0.2  to  0.6  mm.  thick  (Fig.  58).  The 
males  are  much  smaller  than  the  females.  The  oxyuris 
has  three  small  knoblike  lips.  The  female  possesses  two 
uteri  passing  backward  and  forward  from  the  end  of  the 
vagina.  The  opening  of  the  latter  is  situated  above  the 
middle  of  the  body.  The  eggs  are  0.05  mm.  long  and  0.02 
wide.     The  contents  are  granular  and  the  shell  appears 

white. 

24 


"370 


DISEASES  OF  THE  INTESTINES. 


Infection  takes  place  when  the  eggs  of  oxyuris  reach  the 
stomach.     Here  the  shell  opens  and  the  embryo  migrates 

into  the  small  intestine 
(Fig.  59).  After  fructi- 
fication has  taken  place 
the  females  usually  begin 
to  wander  along  the  in- 
testinal canal.  In  the 
caecum  they  generally 
make  quite  a  long  sojourn 
until  the  eggs  are  almost 
ripe.  Then  they  again 
begin  to  pass  down- 
ward. According  t  o 
Leichtenstern,  Lutz,  and 
Huber,  the  females  do  not 
pass  their  eggs  within 
the  intestinal  canal.  As 
a  rule  they  first  leave  the 
For  this  reason  the  fecal 


Fig.  58.— Oxytuls  Vermlcularis :  a,  natural 
size :  b.  head ;  c,  tail,  magnified ;  d,  head 
greatly  magnified. 


bowel  and  then  deposit  the  eggs 

matter  usually'  does  not  contain  any  eggs. 

The  symptoms  which  are  most  frequently  observed  con- 
sist in  pronounced  pruritus  ani  due  to  the  irritation  pro- 
duced by  the  passing  of  the  parasites  out  from  the  rectum. 
Frequently'  the  itching  annoys  the  patient  as  soon  as  he 
retires.  Various  nervous  symptoms  are  occasionally  ob- 
served: anorexia,  nausea,  dizziness,  palpitation  of  the 
heart,  pollutions  and  spermatorrhoea  in  the  male ;  besides 
diarrhoea  occasionally  occurs.  Pronounced  anaemia  is  en- 
countered, although  rarely.  In  rare  instances  the  para- 
sites reach  the  vagina  and  cause  irritation  there.  Nymph- 
omania has  then  been  observed. 

Infection  probably  occurs  through  direct  conveyance  of 


OXYURIS  VERMICULARIS. 


371 


the  eggs  by  the  unwashed  hands  of  the  host.  It  is  also 
possible  that  ova  dried  by  the  sun  exist  on  fruit,  radishes, 
or  salads,  in  which  state  they  may  be  carried  into  the 
stomach. 

The  diagnosis  of  the  thread  worm  is  made  by  inspection 
of  the  anal  region  and  by  the  finding  of  the  oxyuris. 

With  regard  to  prophylaxis  extreme  cleanliness  is  of  the 
greatest  importance.  Fruits  should  be  thoroughly  cleaned 
and  then  peeled  before  they  are  eaten.  The  eating  uten- 
sils of  a  person  infected  with  oxyuris  should  never  be  used 
by  another,  unless  they  have  been  thoroughly  disinfected. 
The  same  applies  to  the  clothes.  Sleeping  with  an  infected 
person  should  be  forbidden,  and  even  touching  his  hands 


Fio.  59.— Development  of  Oxyuris  Vermlciilaris.  CHeller.)  a-e,  Sejnnentation  of  the 
yolk;  /,  ovum  containing  tadpole-shaped  embryo,  seen  from  the  side;  g,  abdominal 
view  of  the  same;  ?),  ovum  with  worm-shaped  embryo;  i,  embryo  escaping  from  the 
shell ;  /f,  free  embryo  capable  of  motion. 

requires  immediate  washing,  as  otherwise  infection  may 
take  place. 

Treatment. — Santonin  is  the  principal  remedy  for  com- 
bating oxyuriasis.     It  is  given  in  the  same  way  as  de- 


372  DISEASES  OF  THE  INTESTINES. 

scribed  in  the  treatment  of  ascaris  lumbricoides.  Here, 
however,  irrigations  of  the  bowel  with  water  and  the  addi- 
tion of  a  few  drops  of  benzene  or  thymol  or  vinegar  (three 
to  four  tablespoonsful  to  a  quart),  or  of  sapo  medicatus  in 
a  one-half  to  one-per-cent  solution  may  be  advantageously 
used.  The  anal  region  should  be  thoroughly  cleansed. 
If  the  pruritus  ani  is  quite  intense,  application  to  the  anal 
region  and  rectum  of  unguentum  hydrarg.  cinerei  or  the 
use  of  a  suppository  of  ung.  hydrarg.  cinerei  1  gm.,  in 
cacao  butter  2  gm.  will  afford  relief. 

Anchylostoma  Duodenale.  Dochmius  Duodenalis  or  Stron- 
gylus  Duodenalis. — This  important  parasite  was  first  de- 
scribed by  Dubini '  in  1838.  Bilharz "  and  Griesinger ' 
recognized  this  parasite  as  the  cause  of  the  Egyptian 
chlorosis.  Some  time  afterward  the  anchylostoma  was 
observed  in  severe  cases  of  anaemia  among  workmen  in 
tunnels  and  brickmakers. 

The  anchylostoma  duodenale  is  cylindrical  in  shape,  0.5 
to  1  mm.  thick  and  6  to  18  mm.  long.  It  is  yellowish  or 
grayish-white  in  color,  with  translucent  edges.  The  male 
is  much  shorter  than  the  female.  The  cephalic  end  is 
curved  toward  the  dorsal  surface  and  is  provided  with  an 
oral  capsule  at  the  margin  of  which  there  are  six  hooklike 
teeth.  Further  within  the  capsule  there  are  three  sharp 
chitinous  processes  (Figs.  60  and  61).  The  male  is  more 
slender  and  transparent  than  the  female.  Its  head  end  is 
bent  backward.  The  tail  end  appears  somewhat  swollen, 
containing  the  bursa  copulatrix,  and  is  much  more  curved 
than  the  head.  In  the  female  the  caudal  end  is  jjointed 
and  armed  with  an  awl-like  prong;    the  genital  opening 

'  Angelo  Dubini:  Gaz.  med.  Lombard.,  1843. 

*  Bilharz:  Wiener  med.  Wochenschr. ,  1856. 

*  Griesinger :  Arch,  f .  physiolog.  Heilkunde,  1854. 


ANCHYLOSTOMA  DUODENALE. 


373 


Fig.  01.— Cephalic  End  of  Anchylostoma  Duo- 
denale.  (Schulthelss.)  a.  Mouth-capsule ; 
b,  teeth  of  ventral  border ;  c,  teeth  of  dorsal 
border;  d,  buccal  cavity:  e,  skin-sac  on 
ventral  side  of  head;  /.muscular  layer;  g. 
dorsal  groove ;  ?i,  oesophagus. 


/i^s 


Fig.  62.— Eggs  of  Anchylostoma  Duodenale. 
(Perronclto  and  Schulthelss.)  a,  b,  c,  d, 
Different  stages  of  cleavage ;  c,  /,  eggs  with 
embryos.    Magnified  300  diameters. 


Fig.  60.— Male  of  Anchylostoma  Duodenale.  (Schulthelss.)  a.  Head  with  mouth-cap- 
sule ;  b,  oesophagus ;  o,  intestine  ;  d,  anal  glands ;  e,  cervical  glands ;  /,  skin ;  g, 
muscular  layer ;  h,  porus  excretorius ;  (,  triple  bursa ;  k.  ribs  of  the  bursa ;  /,  testicu- 
lar canal;  /n,  veslcula  seminalis ;  >i.  ductus  ejaculatorius;  o,  groove  of  latter ;  p, 
penis ;  q,  sheath  of  penis.    Magnified  30  diameters. 


374  DISEASES  OP  THE  INTESTINES. 

lies  behind  the  centre  of  the  body.  The  eggs  are  oval, 
0.06  mm.  in  length  and  0.03  mm.  in  width  (Fig.  62). 

The  habitat  of  the  anchylostoma  is  the  duodenum,  the 
jejunum,  and  the  upper  part  of  the  ileum!  Here  the  worm 
attaches  itself  to  the  intestinal  mucosa  and  feeds  by  suck- 
ing the  blood  of  his  host.  According  to  Leichtenstern, ' 
active  migration  of  the  worm  begins  at  the  time  of  the  first 
copulation  in  the  fifth  week.  Young  worms  change  their 
place  quite  frequently  and  hence  give  rise  to  repeated  hem- 
orrhages. Colic,  and  acute  anaemia  are  encountered  at  an 
early  period  after  infection. 

Under  favorable  conditions  the  eggs  develop  outside  of 
the  body  into  rhabditis-like  larvae,  becoming  enclosed  in 
a  protecting  envelope  or  encysted.  In  this  stage  the  larvse 
may  be  carried  along  with  the  dust  and  contaminate  fruit 
and  water.  On  reaching  the  small  intestine  they  develop 
into  mature  worms.  This  parasite  is  always  encountered 
in  great  numbers  if  present  in  the  intestines.  Leichten- 
stern never  found  them  in  a  smaller  number  than  one 
hundred,  but  sometimes  their  total  reached  three  thou- 
sand. 

The  symptoms  produced  by  anchylostoma  consist  of  gas- 
tralgia,  nausea,  occasionally  vomiting,  constipation,  rarely 
diarrhoea,  and  severe  anaemia,  the  latter  becoming  progres- 
sively worse.  The  patient  with  anchylostoma  does  not 
greatly  emaciate,  but  becomes  pale,  extremelj'  weak,  and 
suffers  from  dizziness  and  shortness  of  breath  after  the 
slightest  exertion.  His  extremities  are  cold,  slight  hemor- 
rhages occur  frequently,  and  cedema  of  the  ankles  devel- 
ops. A  systolic  murmur  may  be  heard  at  the  apex  of  the 
heart,  tlie  pulse  is  accelerated,  and  fever  may  be  present 

'  Leichtensteni :  Centmlbl.  f .  klin.  Medicin,  1885,  and  Deutsche  med. 
Wochenschr.,  1885,  1886,  1887. 


ANCHYLOSTOMA  DUODENALE.         376 

toward  evening.  An  inclination  to  eat  earth  (geophagia) 
is  not  rarely  observed. 

The  dejecta  are  of  a  brownish  color,  although  admixture 
of  blood  cannot '  be  recognized  macroscopically.  Micro- 
scopically Charcot-Ley den's  crystals,  as  well  as  the  eggs 
of  the  parasites,  are  often  found  in  the  stools.  The  urine 
rarely  contains  albumin,  but  frequently  indican.  The  con- 
dition of  the  blood  resembles  that  found  in  pernicious 
ansemia :  enormous  decrease  of  the  red  blood  corpuscles, 
poikilocytosis,  nucleated  red  blood  corpuscles,  and  a  slight 
increase  of  the  leukocytes,  especially  of  the  eosinophile 
cells. 

Anatomically  the  mucosa  of  the  small  intestine  is  found 
greatly  congested  and  ecchymoses  are  visible  here  and 
there.  Peyer's  patches  and  the  solitary  follicles  are  often 
swollen.  The  heart  is  found  hypertrophied  and  dilated, 
the  liver  and  spleen  may  be  diminished  in  size,  normal,  or 
in  an  amyloid  condition.  The  same  can  be  said  of  the 
kidneys.  There  is  no  doubt  that  the  principal  deleterious 
action  of  the  anchylostoma  consists  in  the  profuse  loss  of 
blood  caused  by  the  parasites.  Whether  some  toxic  sub- 
stances generated  by  them  participate  in  producing  the 
grave  symptoms  is  questionable. 

The  course  of  the  disease  is  protracted  and  its  severity 
depends  greatly  upon  the  number  of  parasites  i:)resent.  If 
the  latter  is  great,  the  disease  may  progress  quickly  and 
the  patient  succumb  with  the  symptoms  of  general  dropsy, 
dj  spnoea,  and  heart  failure  or  pulmonar}^  oedema.  If  the 
number  of  the  parasites  is  small,  the  i)atient  may  live 
many  years  and  ultimately  recover  entirely.  Recovery  is 
also  possible  by  successful  expulsion  of  the  parasites  from 
the  intestinal  tract. 

The  diagnosis  of  anchylostomiasis  is  made  by  the  pres- 


376 


DISEASES  OF  THE  INTESTINES. 


ence  of  the  symptoms  of  anaemia  in  conjunction  with  the 
discovery  of  the  anchylostoma  eggs  in  the  dejecta. 

With  regard  to  projyhylaxis  the 
above  given  rules  for  the  prevention  of 
the  round-  and  thread-worms  are  also 
applicable  here.  Extreme  cleanliness 
of  the  body  and  of  the  food  is  of 
greatest  importance. 

The  treatment  consists  in  the  ad- 
ministration of  extract  of  male-fern, 
which  should  be  employed  in  the 
same  manner  as  described  above  for 
the  tapeworm  disease. 

AngidUula  Stercoralis. — This  nema- 
tode is  0,8  to  1.2  mm.  long,  the  male 
shorter  than  the  female  (Fig.  63). 
The  male  is  indigenous  in  Cochin 
China  and  Italy.  In  the  latter  coun- 
try it  often  occurs  simultaneously  with 
anchylostoma.  If  the  worms  exist  in 
large  numbers  they  may  produce  patho- 
logical conditions.  According  to  Golgi 
and  Monti,'  the  anguillula  stercoralis 
penetrates  into  Lieberkuehn's  crypts 
and  there  deposits  its  eggs  and  young. 
AnguiUida  intestinalis,  which  is  2.25 
mm.  long,  belongs  to  the  same  variety 
as  anguillula  stercoralis  and  is  found 
under  the  same  conditions.  Only  the  female  of  this  worm 
is  known.  The  eggs  develop  in  the  intestinal  canal  and 
exhibit  only  the  first  stages  of  segmentation  at  the  time 
of  their  passage  with  the  faeces. 

'  Gk)Igi  e  Monti:  Arch,  per  le  science  med.,  1886,  No.  3. 


no.  63.— Female  of  An- 
guillula  Stercoralis, 
with  E()rKs  and  Embryos. 
(Perronclto.)  Maf^nl- 
fled  85  diameters. 


TRICHOCEPHALUS  DISPAR  377 

Trichocephalns  Dispar.  \Vliip-Worm. — This  parasite  is 
quite  common,  but  comparatively  harmless.  Its  habitat 
is  the  csBCum  and  the  neighboring  section  of  the  intestine. 
It  lives  upon  blood  which  it  abstracts  from  the  intestinal 
mucosa.  This  parasite  is  4-5  cm.  long,  the  male  being 
smaller  than  the  female.  The  head  end,  which  is  about 
three-fifths  of  the  entire  length,  is  drawn  out  into  a  fine 
thread ;  the  tail  end  is  not  so  thin,  being  up  to  1  mm.  in 
thickness  (Fig.  64).  Tho  male  has  a  spiral  body  from  the 
end  of  which  the  spicule  i)rojects.  The  body  of  the  fe- 
male is  straight  and  terminates  in  a  blunt  extremity.     The 


Fig.  64.— Trtchocephalus  Dispar.     (Heller.)    o,       Fio.  65.— Ova  of  Trlchocephalus 
Female .  h,  male.    Natural  size.  Dispar  In  Process  of  Develop- 

ment.   CHuber.) 

ova  are  almost  lemon-shaped,  dark  brown  in  color,  0.05 
mm.  in  diameter  (Fig.  Q5).  The  number  of  eggs  in  a  sin- 
gle female  was  estimated  by  Leuckart  at  68,000.  They  are 
hatched  out  very  slowly. 

Leuckart  asserts  that  the  dispersion  of  the  eggs  and  con- 
sequent spread  of  infection  may  readily  occur  through 
wind,  rain,  or  dust,  and  that  the  eggs  may  be  ingested  with 
fruit  and  salads.  The  number  of  these  worms  found  in 
one  patient  is  usually  small,  from  six  to  twenty. 

The  symptoms  are  but  very  slight,  occasionally  diarrhoea 
exists,  sometimes  there  are  some  reflex  nervous  conditions. 

The  diagnosis  can  usually  be  easily  made  from  the  shape 
of  the  ova.  The  passage  of  the  living  worms  in  the  stools 
occurs  but  rarely. 


378 


DISEASES  OP  THE  INTESTINES. 


Plate  I.— Trichina  Spiralis  (Hubert. 


TRICHINA  SPIRALIS.  379 

With  regard  to  treatment  Lutz  recommends  the  admin- 
istration of  thymol;  Mosler '  and  Peiper""  employ  rectal 
irrigation  of  water,  to  which  a  few  drops  of  benzene  have 
been  added.  Extract  of  male-fern  may  also  be  used  inter- 
nally. 

Trichina  Spiralis. — The  trichina  spiralis  was  discovered 
by  Paget/  but  its  pathological  importance  was  first  recog- 
nized 4)y  Zenker.^  This  parasite  is  observed  in  two  forms, 
the  trichina  of  the  intestine  and  the  trichina  of  the  muscles 
(see  Plate  I.). 

The  trichina  reaches  the  stomach  through  the  ingestion 
of  pork  containing  encapsulated  trichinae.  In  the  stomach 
the  capsule  opens  about  three  to  four  hours  after  the  inges- 

'  Mosler:  " Darminf usion. "  Real- EncyclopMie  der  gesamm ten  Heil- 
kunde,  Bd.  v. 

'  Peiper:  "  Helminthen. "  Real-Encyclopadie  der  gesammten  Heil- 
kunde,  Bd.  ix. 

^  Paget,  cited  after  Huber :  "  Twentieth  Century  Practice  of  Medi- 
cine, "  vol.  viii.,  p.  608. 

■•  Zenker:  Deutsches  Arch,  ftir  klin.  Medicin,  i.,  1866. 

Explanation  ob^  Plate  I. 

Fig.  1.— Muscle  Trichina  Enclosed  in  a  Fully  Developed  Cyst.  X  240.  Cy,  cyst;  Bg, 
connective- tissue  envelope ;  F/f,  fat  globules. 

Fig.  2.— The  Same  Removed  from  the  Cyst.  X  400.  Oe,  (Esophagus ;  Zk,  cell 
bodies ;  L,  side  lines ;  Oi\  ovary ;  Ch.D,  chyle  duct. 

Fig.  3.— Part  of  the  Ovary,  x  603.  Is  readily  distinguished  from  the  testicle  by  the 
varying  size  of  the  germ  cells. 

Fig.  4.— Male  Intestinal  Trichina,  x  100.  T,  Testicle ;  d  ej,  ejaculatory  duct ;  Zk, 
cell  bodies. 

Fig.  5.— Female  Intestinal  Trichina.  X  90.  Ov,  ovary ;  E,  embryos ;  Oe,  geuital 
opening  from  which  the  embryos  escape. 

Fig.  6.— Free  Embryo.    X  400.    O,  mouth;  A,  anus. 

Fig.  7.— Embryo  About  Three  Days  After  Having  Entered  the  Muscle  Fibre.  MF, 
normal  muscle  fibre. 

Fig.  8.~Muscle  Trichina.  About  Six  Days  Old,  in  the  Greatly  Swollen  Sarcolemma 
Sheath  Traversed  by  Capillary  Vessels,  Cap. 

Fig.  9.-Muscle  Trichina,  Four  Weeks  Old,  Enclosed  In  a  Capsule,  Cjy  A,  within  the 
sarcolemma  sheath,  S/c ;  Bk,  connective-tissue  capsule  in  process  of  active  growth ;  fc, 
nuclei ;  MF.  contents  of  the  sarcolemma  sheath  at  each  pole  of  the  capsule. 

Fig.  10.— Muscle  Trichina  with  CalciUed  Capsule.    Fk,  Fat  globules. 


380  DISEASES  OP  THE  INTESTINES. 

tion  of  the  meat  and  the  embryos  rapidly  develop.  At  the 
end  of  thirty  to  forty  hours  fructification  of  the  young  par- 
asites takes  place. 

The  intestinal  trichinse  are  visible  with  the  naked  eye, 
the  females  being  3  to  4  mm.  long  and  the  males  half  this 
size.  The  caudal  extremity  is  thicker  than  the  head  end. 
Five  days  after  fecundation  the  females  give  birth  to  living 
young  ones.  The  young  brood  wanders  directly  frdm  the 
intestine  of  the  host  into  his  muscles.  Here  thej-  further 
develop.  In  this  coijdition  they  give  rise  to  a  febrile  dis- 
ease accomi)anied  by  severe  muscular  symptoms  which 
may  lead  to  death.  Sometimes  the  trichinae  become  en- 
capsulated. The  symptoms  vary  according  to  the  number 
of  worms  which  have  been  ingested.  Gastro-intestinal  dis- 
turbances usually  appear  on  the  second  or  third  day  after 
the  ingestion  of  the  contaminated  meat.  Vomiting,  diar- 
rhoea, colic  often  appear. 

The  disease  known  as  trichinosis,  which  depends  upon 
the  further  develoj^ment  of  the  young  embryos  in  the  mus- 
cles of  the  host,  is  not  within  the  scope  of  this  book,  and 
we  refer  to  this  parasite  only  as  far  as  its  occurrence  in 
the  intestines  is  concerned.  With  regard  to  prophylaxis 
pork  should  never  be  eaten  raw.  The  treatment  after  the 
ingestion  of  trichinous  meat  consists  in  the  employment  of 
lavage  of  the  stomach,  if  the  physician  is  called  early  enough 
after  the  meal.  In  addition  a  vermifuge  and  cathartic  rem- 
edy should  be  given  immediately. 


INDEX. 


Abelmann,  22 

Absorption  as  a  function  of  the 

bowel,  24 
Acholic  stool,  58 
Adenoma  of  the  intestines,  167 
^Egineta,  Paulus,  335 
Albumin  in  the  faeces,  53 
Albuminates,  putrefaction  of,   in 

the  large  intestine,  21 
Alimentation,  rectal,  77 

subcutaneous,  77 
Allingham,  37,  172,  185,  188 
Allingham's  rectal  speculum,  37 
Amoeba,  349 
Amoebic  dysentery,  110 
Amyloid  ulcers,  140 
Anacker,  311 

Anaesthesia  of  the  intestine,  383 
of  the  rectum,  333 

treatment,  334 
Anatomy  of  the  intestine,  1 
Anchylostoma  duodenale,  372 

course,  375 

diagnosis,  375 

prophylaxis,  376 

symptoms,  374 

treatment,  376 
Angioma  of  the  intestines,  167 
Anguillula  intestinalis,  376 

stercoralis,  376 
Antiperistalsis    of    the   intestine, 

30 
Anus,  anatomy  of  the,  16 

fissure  of  the,  193 
Appendicitis.  196 


Appendicitis,  definition,  196 
diagnosis,  214 
differential  diagnosis,  315 
etiology,  197 
general  remarks,  196 
morbid  anatomy,  203 
prognosis,  216 
symptomatology,  206 
synonyms,  196 
treatment,  218 
catarrhal,  202 

indications  for  operation,  225 
perforativa,  204 
severe  form,  204 
ulcerosa  et  gangraenosa,  204 
Appendicular  inflammation,  196 
Appendix  vermiformis,  13 
Areta;us,  110 
Ascariasis,  diagnosis,  367 
prophylaxis,  368 
symptoms,  367 
treatment,  368 
Ascaris  lumbricoides,  365  ' 

mystax,  369 
Atony  of  the  bowel,  291 
Auscultation,  45 
Awl-tail,  369 

Bai.antidit'm  coli,  351 
Bamberger,  200 
Barbacci,  200 
Barthelemy,  114 
Basoh,  55 
Bauhin's  valve,  13 
Baylc.  141 


382 


INDEX. 


Beauchef,  111 

Beck,  Carl,  198,  222 

Benign  tumors  of  the  intestines, 

167 
Bernard,  Claude,  19 
Bienstock,  74 

Bile  pigment  in  the  faeces,  57 
Bilharz,  372 

Bilharzia  haematobia,  364 
Biliary  acids  in  the  faeces,  57 
Birch-Hirschfeld,  144 
Blood  in  the  faeces,  56 
Boas,  J.,  42,  48.  90.  213,  214,  219, 

220.  221.  224,  339 
BOnnecken,  248 
Borborygmi,  45 
Bothriocephalus  cordatus,  359 

latiis,  357 
Bouchard,  99,  298 
Boudet,  81,  263,  309 
Bougies,  rectal,  43 
Bowel,  atony  of  the,  291 
Brahm-Houkgeest,  28,  283 
Brinton,  254 
Brooks,  LeRoy  J.,  267 
Brunner's  glands,  9 
Brunton,  324 
Bryant,  J.  D.,  13,  151 
Bull,  W.  T.,  197,  223 
Bunge,  59 

Cjecvm,  anatomy  of  the,  12 
Cahn,  261 

Cancer  of  the  duodenum,  symp- 
toms, 159 
of  the  intestine,  150 

course.  163 

definition.  150  » 

diagnosis,  163 

etiology,  150 

location,  151 

morbid  anatomy,  152 

prognosis,  164 

symptomatology,  154 

treatment,  164 


Cancer  of  the  large  bowel,  syhip- 
toms,  160 

of  the  rectum,  symptoms,  161 

of  the  small  intestines,  symp- 
toms, 160 
Carbohydrates  in  the  faeces,  54 
Carbolic-acid  injections  in  hemor- 
rhoids, 186 
Cash,  324 
Catarrh,  acute  intestinal,  83 

chronic,  of  the  bowels,  94 
Cauterization  in  hemorrhoids,  186 
Celsus,  110 

Cercomonas  intestinalis,  350 
Cestodes,  351 
Charcot,  286 
Chlapowski,  40 
Cholera  nostras,  83 
Clapotage,  42 
Clark,  Alonzo,  220,  302 
Colic,  intestinal,  326 

mucous,  335 
Colitis,  acute,  90 
Colon,  anatomy  of  the,  11 

ascending,  14 

descending,  15 

transverse,  14 
Compression  of  the  intestine,  227 
Concretfons  in  the  faeces,  59 
Constipation,  291 

definition,  291 

dependent    upon    other    dis- 
eases, 296 

diagnosis,  302 

etiology.  292 

habitual,  291 

prognosis,  304 

prophylaxis,  304 

symptomatology  297, 

synonyms,  291 

treatment,  304 
dietetic,  305 
mechanical,  306 
moral,  305 
Cooper,  187 


INDEX. 


383 


Cooper-Forster,  155 

Cornil,  342 

Councilman,  113,  115,  118 

Crede,  279 

Crushing   in    the    treatment    of 

liemorrhoids,  188 
Cruveilhier,  171,  337 
Curschmann,  258,  264 
Cysts  of  the  intestines,  167 

Da  Costa,  337,  338,  344 
Damsch,  46 
Dastre,  19 
Dcaver,  222 
Demant,  282 
Delafield,  F..101 
Diarrha^a,  284 

acute,  83 

diagnosis,  289 

dyspeptic,  287 

etiology.  284.  288 

membranous,  335 

morning,  101 

nervous,  284 

prognosis,  289 

stercoral,  288 

symptomatology,  284,  288 

treatment.  289 

tubular,  335 
Diet,  74 
Dilatation  of  the  sphincters  in  the 

treatment  of  hemorrhoids,  185 
Distoma  lucmatobium,  364 

hepaticum,  362 

lanceolatum.  363 
Dochmius  duodeualis,  373 
Douglas'  fold,  15 
Doumer,  309 
Dubini,  372 
Dunin,  294 
Duodenal  ulcer.  128 
course,  133 
definition,  128 
diagnosis,  133 
etiology,  128 


Duodenal  ulcer,  morbid  anatomy, 
129 
prognosis,  134 
symptomatology,  131 
synonyms,  128 
treatment,  134 
Duodenitis,  acute,  89 
Duodenum,  anatomy  of  the,  1 
Dutrouleau,  121 
Dynamic  ileus,  257 
Dysentery,  110 
amoebic,  110 
complications,  123 
course,  123 
definition,  110 
diagnosis,  125 
etiology,  110 
morbid  anatomy,  115 
prognosis,  125 
symptomatology,  119 
synonyms,  110 
treatment,  125 
Dyspeptic  diarrhoea,  287 

Edebohls,  198,  207,  208 
Edwards,  388 
Ehrlich,  338,  342 
Ehrmann,  31 
Eichberg,  113 
Eichhorst,  131 
Eisenlohr,  139 

Electricity  in  intestinal  obstruc- 
tion, 263 
in  the  treatment  of  constipa- 
tion, 308 
in  the  treatment  of  disease,  81 
Elsberg,  C.  A.,  70 
Embolic  ulcers,  135 
Embolus  of  the  arteria  mesaraica 
superior,  136 
of  the  inferior  mesaraic  artery, 
139 
Endo-appendicitis.  203 
Enemata  in  the  treatment  of  con- 
stipation. 310 


384 


INDEX. 


Enteralgia,  326 

definition,  326 

diagnosis,  329 

etiology,  326 

prognosis,  330 

symptomatology,  327 

synonyms,  326 

treatment,  330 
Enteritis,  acute,  83 

chronic,  94 

crouposa,  110 

membranous,  335 

necrotica,  110 
Enterospasmus,  295 
Erdmann,  John  F.,  267 
Escherich,  73,  200 
Esmarch,  189 
Ewald,  C.  A..  62,  96, 131,  219,  220, 

224,  339.  340 
Examination,  methods  of,  32 
Extirpation  of  hemorrhoids,  189 

F^CES,   abnormal  admixtures  in 

the,  51 
albumin  in  the,  53 
bile  pigment  in  the,  57 
biliary  acids  in  the,  57 
blood  in  the,  56 
carbohydrates  in  the,  54 
chemical  examination  of  the, 

52 
concretions  in  the,  59 
examination  of  the,  49 
fat  in  the,  55 
ferments  in  the,  59 
fragments  of  tumor  in  the,  51 
micro-organisms  in  the,  71 
microscopical  examination  of 

the.  62 
mucin  in  the,  53 
odor,  50 

peptone  in  the,  54 
propeptone  in  the,  54 
pus  in  the,  51 
reaction  of  the,  52 


Faeces,  remnants  of  food  in  the,  51 
Fat  in  the  faeces,  55 
Fecal  accumulation  as  a  cause  of 
chronic  obstruction,  273 

fever,  302 

tumors  complicating  constipa- 
tion, 300 
Ferguson,  E.  D,  233,  267 
Fermentation  test,  Schmidt's,  55 
Ferments  in  the  faeces,  59 

of  the  pancreas,  19 
Fever,  fecal,  302 
Fibroma  of  the  intestines,  167 
Finger  cot,  42 
Fischel,  286 
Fischl,  89 

Fissure  of  the  anus,  193 
Fitz,  Reginald,  114,  197,  222,  258 
Flatau,  312 
Flatulency,  321 
Fleiner,  79,  262,  311,  346 
Fleischer,  59,  214,  282 
Fluke  worms,  362 
Foreign  bodies,  obturation  by,  234 
Fowler,  197,  199,  200,  202,  214,  222 
Frentzel,  265 
Frerichs,  141 
Friedenwald,  J.,  43 
Fttrbringer,  265 

Gall  stones,  obturation  by,  233 

Galvano-cautery  in  the  treatment 
of  hemorrhoids,  188 

Gerhardt,  137 

Gerr}-,  114 

Gersuny,  41 

Gibson.  C.  L.,  266 

Glycerin  injections  in  the  treat- 
ment of  constipation,  311 

Golgi,  376 

Good,  Mason,  336 

Gouley,  J.  W.,  267 

Graser,  189,  259,  264,  265 

Grasse,  367 

Graves,  220 


INDEX. 


385 


Grawitz,  139 

Gricsiuger,  372 

Grisolle,  196,  197,  220 

Guttmaiin,  P.,  204 

Gymnastic  exercises  in  the  treat 

ment  of  constipation,  308 
exercises  in  the  treatment  of 

disease,  80 

llABEHsnoN,  79,  300 
Habitual  constipation,  291 
Hackel.  309 
Haguenot.  241 
Hall,  Marshall,  87 
Hammarsten,  26 
Harris,  113,  114,  116,  127 
Haustra  coli,  12 
Hawkes,  F.,  223 
Hegar,  139 
Hemorrhoids,  169 

complications,  189 

definition,  169 

diagnosis,  179 

etiology,  169 

morbid  anatomy,  171 

prognosis,  180 

symptomatology,  174    ^ 

synonyms,  169 

treatment,  180 
radical,  185 
Henrot,  314 
Heryng,  39 
Heusgeu,  155 
Hippocrates.  110 
Hirschler,  22 
Hlava,  113 
Hodenpyl,  200 
Hoffmann,  265 
Houston,  186 
Hoyer,  338 
Huber,  356.  366,  370 
Hydrocephaloid,  acute,  87 
Hydrotherapy,  80 

in  the  treatment  of  constipa- 
tion. 309 
25 


Hyperaesthesia  of  the  intestine,  333 
Hypogastric  neuralgia,  332 
treatment,  332 

Ileo-C/KCAL  valve,  13 
Ileum,  anatomy  of  the,  4 
Ileus,  227 

dynamic,  257 
Illoway.  307 
Incarceration,  acute,  255 
Inflation  of  the  bowel  with  air  in 
intestinal  obstruction,  262 
of  the  intestine,  45 
Infusoria,  350 
Injection  of  water  per  anum  for 

examination,  48 
Injections  as  a  method  of  treat- 
ment, 78 
in  the  treatment  of  constipa- 
tion, 310 
Inspection,  34 
Interrogation,  32 
Intestinal  catarrh,  acute,  83 
definition,  83 
diagnosis,  91 
duration,  90 
etiology,  83 
localization,  89 
morbid  anatomy,  85 
prognosis,  91 
symptomatology,  86 
synonyms,  83 
treatment,  91 
catarrh,  chronic,  94 
course,  103 
definition,  94 
diagnosis,  103 
etiology,  94 
morbid  anatomy,  95 
symptomatology,  98 
synonyms,  94 
treatment,  105 
colic,  326 
neurasthenia,  347 
diagnosis,  348 


386 


INDEX. 


Intestinal  neurasthenia,  treatment, 
MS 
obstruction,  226 
obstruction,  acute,  226 

course,  247 

definition,  227 

diagnosis,  249. 

etiology.  227 

location   of  the  obstruc- 
tion, 251 

objective  signs,  245 

pathological  changes,  236 

recognition,  249 

recognition  of  the  differ- 
ent forms,  255 

symptomatology,  238 

synonyms,  227 

treatment,  258 

treatment,  medical,  258 

treatment,  surgical,  266 
obstruction,  chronic.  268 

complications,  276 

course,  277 

diagnosis,  277 

etiology,  268 

prognosis,  277 

symptomatology,  269 

treatment,  278 

treatment,  surgical,  280 
parasites,  349 
vertigo,  301 
Intestine,  anatomy  of  the,  1 
anaesthesia  of  the,  333 
compression  of  the,  227 
hypera^sthesia  of  tlie,  333 
obturation  of  the,  233,  256 
parsesthesia  of  the,  35^3 
strangulation  of  the,  228 
Intestines,  motor  neuroses  of  the, 
284 
neoplasms  of  the,  150 
nervous  affections  of  the,  282 

classification.  283 
paralysis  of  tlie.  314 

diagnosis.  315 


Intestines,  paralysis  of  the,  treat- 
ment, 315 
peristaltic  restlessness  of  the, 

319 
secretory    neuroses    of    the, 

335     " 
sensory  neuroses  of  the,  326 
ulcers  o{  the,  128 
Intussusception,  234.  256 

agonal,  236 
Irrigator,  Kemp's  rectal,  79 

Jaffe.  2.53 
v.  Jaksch,  54 
Jejuuitis,  acute,  89 
Jejimtmi,  anatomy  of  the,  4 
Jurgens.  97 

Kaiin,  Arthur,  308 
Kartulis.  112.  113 
Kelly,  37 

Kelly's  rectal  speculum,  38 
Kelsey,  186 

Kemp's  rectal  irrigator.  79 
Kerkring's  valves,  8 
Kittagawa,  339 
Klebs.  144 
Klenfperer.  310.  311 
Klubbe,  262 
Koch,  112 
K(K:her,  264 
Koenig,  269 
Korle,  265 
Kos,sobudskj,  184 
Kraus.  129 
Kuhn.  44 
Kundmt.  166 

Kussmaul,  137,  261,  262,  309,  311. 
34(5 

Laboi:i-bene,  337 
Lafleur.  113,  115,  118 
Lambl,  112 
I^nge,  F.,  186.  192 
Langenbeck,  188 


INDEX. 


387 


Large  bowel,  physiologj-  of  the, 
18 
structure  of  the,  17 
intestine,  anatomy  of  the,  11 
Lavage  of  the  bowel,  48 

in  intestinal  obstruction, 
262 
of  the  stomach"  in  intestinal 
obstruction,  261 
Laveran,  124 
Legueu,  F.,  222 
Leichtenstern,   67,   226,   228,  295, 

367,  368.  370,  374 
Lemazurier,  300 
Lenander,  197 
Leube,  77,  134,  301 
Leubuscher,  309 
Leuckart,  356,  367.  377 
Levi,  300 

V.  Leyden,  214,  338,  342 
Lieberkalm's  glands.  9 
Ligature  in  hemorrhoids,  187 
Limbourg,  22 
Lindberger,  22 
Lipoma  of  the  intestines,  167 
Litten,  136 
Liver  fluke,  362 
Loesch,  112 
Ludwig,  25 
Lusk,  19,  26 
Lutz,  367.  370,  379 
Lympho-sarcoma  of  the  intestines, 
166 

Macfadyen.  20,  72 
Madelung,  167 
Malmsten,  351  , 
Marcy,  H.  0.,  267 
Matterstock,  201 
Maggot -worm.  369 
Mannaberg,  73 

Massage  in  intestinal  obstruction, 
263 
in  the  treatment  of  constipa- 
tion. 306 


Massage  in  the  treatment  of  dis- 
ease, 80 
Massaiutiu,  113 
Massloff,  282 
Mathews,  90 
Mayer,  128 
Mayor,  A.,  90 
McBurney,  41,  197,  223 
McCosh,  A.  J.,  223 
Meckel's  diverticulum,  strangula- 
tion by.  230 
Membmnous  diarrha?a,  335 
enteritis,  335      . 

(letinition,  335 

diagnosis.  343 

etiology.  339 

history,  335 

symptomatology,  341 

synonyms.  335 

treatment,  344 
Mendelson.  Walter,  339 
Mercury,    metallic,   in    intestinal 

obstruction.  265 
Meteorism.  321 
diagnosis.  323 
etiology,  321 
prognosis.  323 
symptomatologj',  322 
treatment,  323 
Meydl,  151 

Meyer,  Willy,  223,  324 
IVIicro -organisms  in  the  faeces,  71 
Miller,  22 
Minich.  61 
IMinkowski,  28,  47 
Miserere.  227 
Monti.  376 
Moreau,  282 
Morgagni,  336 
Morris,  R.  T.,  208,  223 
Mosler,  379 

Motion  of  the  intestine,  28 
Mucin  in  the  faeces,  53 
^lucous  colic,  335 
MiiUer.  Max.  152 


388 


INDEX. 


Munk,  25,  27 

Murphy.  222,  280 

Murphy's  button,  obturation  by, 

234 
Musser,  113 
Myoma  of  the  intestines,  167 

Nasse,  113 
Nematodes,  365 
Nencki,  19,  20,  72 
Neoplasms  of  the  intestines,  150 
Nervous  affections  of  the   intes- 
tines, 282 
diarrhoea,  284 
Neuralgia,  hypogastric,  332 

mesenterica,  326 
Neurasthenia,  intestinal,  347 
Neuroses  of  the  intestines,  motor, 
284 
secretory,  335 
sensory,  325 
V.  Noorden,  C,  56,  344,  345 
Nothnagel,  28,  30,    74,    138,  150, 
166,  197,  202,  214,  217,  220,  224, 
235,  269,  283,  285,  294,  302,  338, 
842 
Nuttal,  72 

ObsTI  PATIO,  291 

Obstruction,  intestinal,  226 
Obturation  of  the  intestine,  233, 

256 
Oil  injections  in  the  treatment  of 

constipation,  311 
Opium  in  intestinal   obstruction, 

259 
Oppolzer,  330 
Osier.  113 

■  Oxyuris  vermicularis,  369 
diagnosis,  371 
prophylaxis,  371 
symptomatology,  370 
treatment,  371 

Paget,  379 


Palpation,  40 

Pancreatic  juice,  digestive  power 

of,  19 
Paresthesia  of  the  intestine,  333 
Paralysis  of  the  intestines.  314 
of  the  sphincters  of  the  anus, 
317 

diagnosis,  318 

prognosis,  318 

treatment,  318 
Paranuecium  coli.  351 
Parasites,  intestinal,  349 
Paratyphlitis,  196 
Parenski,  135 
Paresis  of  the  sphincters  of  the 

anus,  317 
Pariser,  53,  339,  342 
Passio  iliaca,  227 
Pean,  280 
Peiper,  379 

Penzoldt,  214,  219,  220,  224 
Peptone  in  the  faeces,  54 
Percussion.  44 

Peristalsis  of  the  intestine,  28 
Peristaltic  restlessness  of  the  in- 
testines, 319 

definition.  319 

diagnosis.  320 

etiology,  319 

symi)tomatology,  319 

treatment,  320 
Perityphlitis,  196 
Petriquin,  220 
Pettenkofer,  57 
Peyer,  285 
Peyer's  patches,  11 
Pflager,  30 

Phlebectasia  hemorrhoidalis,  169 
Pighead,  357 
Piles,  169 

arterial.  172 
capillary,  172 
venous.  173 
Pilliet,  139 
Pin-worm,  369 


INDEX. 


389 


Plica  Doiiglasii,  15 
Poelchen,  145 

Polypi  of  the  intestines,  167 
Pooley,  186 
Proctitis,  90 
Proctoscopy,  37 
Proctospasmus,  316 
diagnosis,  317 
treatment,  317 
Prolapse  of  the  rectum,  189 
Propeptone  in  the  faeces,  54 
Protozoa,  349 
Puncture  of  the  bowel  in  intestinal 

obstruction,  264 
Purgatives  in  the  treatment    of 

constipation,  312 
Putrefaction  of  albuminates  in  the 

large  intestine,  21 

Quincke,  50,  113,  282 

Rachfokd,  19 

Rectnl  alimentation,  77 

bougies,  43 

electrode,  81 

specula,  37 
Rectum,  anaesthesia  of  the,  333 

anatomy  of  the,  15 

prolai)se  of  the,  189 
Reichmann,  39 
Ribbert,  198 
Riedel,  202,  224 
Rieder,  66 
Roentgen  mys  in  examination  of 

the  bowel,  39 
Romberg,  332 
Rose,  A.,  263,  307 
Rosenbach,  46,  247 
Rosenheim,  102,  167,  308,  315,  319, 

323,  347 
Rosenstein,  25,  27 
Ross,  113 
Rothmann,  338 
Rotter,  197 
Round-worms,  365 


Roux,  186,  197 
Rubner,  27 
Ruedi,  297 
Runeberg,  46 
Rushmore,  J.  D.,  267 

Sahu,  197,  217,  220,  307,  324 
Salmon,  187 
Salvioli,  25 
Sands,  197 

Sarcoma  of  the  intestines,  166 
Sasaki,  97 
Schiflf.  28 
Schmidt,  54,  58 

Schmidt's  fermentation  test,  55 
Schmidt-Mtthlheim,  25 
Schmitz,  22 
Schnetter,  46 
Schoening,  150 
Schuberg.  113 
Scolecoiditis,  196 
Seat-worm,  369 

Secretory   function   of  the  intes- 
tines, 18 
neuroses  of  the  Intestines,  335 
Senator,  302 
Senn,  263 
Sennertius,  336 
Sieber,  20,  72 ' 

Sigmoid  flexure  of  the  colon,  15 
Simon,  43 
Sims,  37 

Sims'  rectal  speculum,  37 
Siredey,  F.,  336,  344 
Small  intestine,  anatomy  of  the,  4 

structure  of  the,  6 
Sodre,  111,  116,  126 
Solitary  follicles  of  the  intestines, 

10 
Sonnenburg,  197,  214,  224 
Spasm  of  the  rectum,  316 
Spasmodic     contraction    of     the 

bowel,  295 
Specula,  rectal,  37 
Spool- worm,  365 


390 


INDEX. 


Sporozoa,  350 

S  romanum,  15 

Starke,  129 

Stein,  R.,  224 

Stengel,  113 

Stercoral  diarrhoea,  288 

Stewart,  267 

Stockton,  113 

Stokes,  220 

Stool,  acholic,  58 

Strangulation  of  the  intestine,  228 

Stricture  of  the  rectum  as  a  cause 

of  chronic  obstruction,  275 
Strongylus  duodenalis,  372 
Subcutaneous  alimentation,  77 
Sutton,  E.  M.,  47 
Syms,  Parker,  267 
Syphilitic  ulcers,  144 

T^NiA  cucumerina,  358 

diminuta,  359 

flavopunctata,  359 

lata,  357 

mediocanellata,  355 

nana,  358 

saginata,  355 

solium,  354 
Taeniae  of  the  large  intestine,  12 
Talamon,  197 
Tapeworms,  351 

prophylaxis,  359 

treatment,  359 
Tavel,  200 
Thermocautery  in  the   treatment 

of  hemorrhoids,  188 
Thierfelder,  72 
Thread-worm,  369 
Thrombotic  ulcers,  135 
Thrombus  of  the  mesenteric  veins, 

139 
Toxic  ulcers,  145 
Transillumination  of  the  bowel,  39 
Trastour,  262 
Treatment,  methods  of,  74 
Trematodes,  362 


Trematodes,  treatment,  365 
Treves,  192,  214,  236,  240,  259.  262, 

264,  266,  268,  270,  271,  281 
Trichina  spiralis,  379 

symptoms,  380 
Trichinosis,  380 

prophylaxis,  380 
treatment,  380 
Trichocephalus  dispar.  877 

diagnosis,  377 

symptoms,  377 

treatment,  379 
Trichomonas  intestinalis,  350 
Trousseau,  284 
Tuberculous  ulcers,  141 
Tubular  diarrhoea,  335 
Tympanites,  321 

Ulcer,  duodenal,  128 
Ulcei-s,  amyloid,  140 

embolic,  135 

of  the  intestines,  128 

syphilitic,  144 

thrombotic,  135 

toxic,  145 

tuberculous,  141 
Urobilin  in  the  faeces,  57 

Valve,  ileo-ciccal,  13 

of  Bauhin,  13 
Valvulae  conniventes  Kerkringi,  8 
Van  Cott,  199,  201 
Vennes,  351 

Vermiform  appendix,  13 
Verneuil,  185 
Vertigo,  intestinal,  301 
Virchow,  140 
Voit,  19,  24,  26 
Volkmann,  162 
Volvulus.  232.  255 
Volz,  201.  220 

Wallace*  319 
Weber,  L..  108 
Weigert,  338 


INDEX. 


391 


Weir,  197 
AVertheimer,  330 
"Whfp-worm,  377 
Whitehead,  189,  336,  344 
Wig^nn,  Fred.  H.,  267 
Willigk,  129 
Wilson,  200 
Wolf,  H.  J.,  234 


Woodward,    83,    96,   269,    292, 

336 
Worms,  intestinal,  351 

Zenker,  379 
Ziemssen,  45,  263,  264 
Zuckerkandl,  198 
Zunker,  350 


WI  1+00 
E35d 
1900 
Eihom,  Max  x 

Diseases  of  the  intestines. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE.  CALIFORNIA  92664 


A     000  421  703     o 


